Grant C A, Dempsey G, Harrison J, Jones T
Critical Care Unit, University Hospital, Aintree, Liverpool, UK.
Br J Anaesth. 2006 Jan;96(1):127-31. doi: 10.1093/bja/aei282. Epub 2005 Nov 18.
Tracheo-innominate artery fistula (TIF) is an uncommon yet life threatening complication after a tracheostomy. Rates of 0.1-1% after surgical tracheostomy have been reported, with a peak incidence at 7-14 days post procedure. It is usually fatal unless treatment is instituted immediately. Initial case reports of TIF resulted from surgically performed tracheostomies. We present three fatalities attributable to TIF, confirmed by histopathology, after percutaneous dilatational tracheostomy (PDT). The use of PDT has resulted in tracheostomies being performed by specialists from different backgrounds and the incidence of this complication may be increasing. Pressure necrosis from high cuff pressure, mucosal trauma from malpositioned cannula tip, low tracheal incision, radiotherapy and prolonged intubation are all implicated in TIF formation. Massive haemorrhage occurring 3 days to 6 weeks after tracheostomy is a result of TIF until proven otherwise. We present a simple algorithm for management of this situation. The manoeuvres outlined will control bleeding in more than 80% of patients by a direct tamponade effect. Surgical stasis is obtained by debriding the innominate artery proximally, then transecting and closing the lumen. Neurological sequelae are few. Post-mortem diagnosis of TIF may be difficult, but specific pathology request should be made to assess innominate artery abnormalities.
气管无名动脉瘘（TIF）是气管切开术后一种罕见但危及生命的并发症。手术气管切开术后的发生率报告为0.1% - 1%，术后7 - 14天发病率达到峰值。除非立即进行治疗，否则通常是致命的。TIF的最初病例报告源于手术气管切开术。我们报告了3例经组织病理学证实的经皮扩张气管切开术（PDT）后因TIF导致的死亡病例。PDT的使用使得来自不同背景的专科医生都能进行气管切开术，这种并发症的发生率可能正在上升。高套囊压力导致的压迫性坏死、套管尖端位置不当引起的黏膜损伤、低位气管切口、放疗以及长时间插管都与TIF的形成有关。气管切开术后3天至6周出现的大量出血是TIF的结果，除非有其他证明。我们提出了一种针对这种情况的简单处理方法。所概述的操作将通过直接压迫作用控制超过80%患者的出血。通过在无名动脉近端清创，然后横断并封闭管腔来实现手术止血。神经后遗症很少见。TIF的尸检诊断可能困难，但应提出特定的病理检查要求以评估无名动脉异常情况。
