Tracheoinnominate artery fistula after laryngotracheal separation: prevention and management.

Tracheoinnominate artery fistula (TIF) is an often fatal complication of laryngotracheal separation (LTS) for which there has been no systematic therapeutic strategy for prevention or management of TIF. The aim of this study was to establish such a strategy based on our clinical experience.From 2000 to 2010, 14 patients received LTS. We reviewed these patients to develop a therapeutic approach to prevent or manage TIF.Three patients had major bleeding, and another 3 received preventive treatment before major bleeding. In the major bleeding group, 1 patient died of choking from uncontrollable hemorrhage, but the others were rescued by brachiocephalic trunk separation and/or endovascular embolization. At operation, median sternotomy with its high risk of mediastinitis was avoided. In the preventive treatment group, prophylactic brachiocephalic trunk separation was performed for 2 patients because their severe scoliosis narrowed the mediastinum, compressing the innominate artery on computed tomography. Another avoided major bleeding by converting the tracheostomy tube to a length-adjustable type.Tracheoinnominate artery fistula is a dramatic, often lethal complication. The strategic approach should be designed to prevent it and includes evaluation of the spinal deformity on computed tomography, brachiocephalic trunk separation at the same time as LTS, and recognizing the importance of "herald" or warning minor bleeds.