A Deadly Connection: Recognizing and Preventing Tracheo-Brachiocephalic Artery Fistula

ABSTRACT: Tracheo-Brachiocephalic Artery Fistula is a rare but fatal complication of tracheostomy, with a very high mortality rate. In this paper, we present a case that was diagnosed early and successfully treated with optimal surgical intervention. The patient was a 57-year-old male admitted to the hospital under the care of the neurosurgery team for urgent, life-saving surgery—an evacuation of a left chronic and subacute subdural hematoma. He was intubated in the emergency room upon admission and subsequently transferred to the operating theater for surgery. Later, a tracheostomy was performed due to the need for prolonged intubation. Three months after the tracheostomy, the patient developed massive bleeding from the tracheostomy site. An otolaryngologist was consulted and ordered an emergency CT carotid angiography with IV contrast, which revealed an abnormal fistulous communication between the brachiocephalic artery and the upper anterior tracheal wall, approximately 3 cm below the cricoid cartilage. The fistula measured about 5 mm in length. The otolaryngologist advised increasing the tracheostomy tube cuff pressure to 50 mmHg and urgently consulted vascular surgery, interventional radiology, and the cardiothoracic surgery team for appropriate intervention to control the bleeding. The vascular surgery team reported that they could not control the bleeding, as the fistula was located in the chest rather than the neck, necessitating an emergency intervention either by an interventional radiologist for stent placement or a cardiothoracic surgeon for surgical closure. The interventional radiologist assessed the patient and concluded that the tracheostomy site was infected, significantly increasing the risk of stent infection; therefore, stent placement was not recommended. The cardiothoracic surgery team then evaluated the patient, immediately transferred him to the operating theater, and successfully closed the fistula, controlling the massive bleeding under general anesthesia. This case highlights the critical importance of rapid multidisciplinary collaboration and prompt intervention in the successful management of tracheo-brachiocephalic artery fistula. Key Words: Tracheo-Brachiocephalic Artery Fistula, tracheostomy, complications, tracheo-innominate artery fistula, diagnosis, surgery, fistula, hemorrhage, TIF.