Abstract
Percutaneous tracheostomy is a common procedure that can be performed bedside by intensivists. The widespread adoption of bronchoscopy and ultrasound have also been utilized in the Intensive Care Unit (ICU), leading to the decline of conventional surgical tracheotomy. Percutaneous tracheotomy is thought to have several advantages over conventional tracheotomy. These include a smaller skin incision, less dissection and tissue trauma, and fewer wound complications. Long term complications have also been reported less frequently. One of the possible complications of performing these procedures is innominate artery injury, considered a rare but lethal injury. Injury to the innominate artery occurs in multiple different manners, including blunt, penetrating, or iatrogenic trauma.
We report a case of percutaneous tracheostomy complicated by injury to the innominate artery, requiring a conversion to an emergent open surgical tracheostomy. This case report illustrates the potentially fatal complication from performing a percutaneous tracheostomy, highlights the causes and management of innominate artery injury, and provides review of the literature this rare and uncommon complication.
Highlights
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Innominate artery injury during percutaneous tracheostomy is an extremely rare clinical emergency.
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Understanding vascular anatomical variations during surgery is crucial for patients who require emergency tracheostomy due to obstructed or injured airways, including patients with maxillofacial trauma.
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An open surgical tracheostomy approach should be considered for patients with challenging anatomical variations.
1
Introduction
Tracheostomy is one of the oldest and most performed procedures for critically ill patients [ ]. Jackson first described surgical tracheostomy (ST) in 1909, and its adoption in Intensive Care Units (ICUs) increased during the polio epidemic of the 1950s [ ]. In 1985, Ciaglia introduced the percutaneous tracheostomy (PCT) technique using a guidewire, which has since become the standard in ICUs, largely replacing ST for this patient population [ ].
PCT has become widely used in ICUs, nearly replacing ST. This shift is largely due to the ease of performing PCT at the bedside, which helps avoid unnecessary and often risky transfers to the operating theater, along with its cost-effectiveness [ ].
ST is superior to PCT where anatomical landmarks are hard to identify, if there is a malignancy at the insertion site, or when an emergency tracheostomy is necessary [ ]. In addition, (PCT) is an absolute contraindication in infants and where there is infection near the surgical site [ ]. In addition, its contraindicated in unstable cervical spine injury which is commonly seen in patients with maxillofacial injuries [ ].
The innominate artery (IA) sometimes arches anteriorly over the trachea up to the second tracheal ring [ ]. Understanding vascular anatomical variations during surgery is crucial for patients who require emergency tracheostomy due to obstructed or injured airways, including patients with maxillofacial trauma [ ].
Injury to the IA is a rare but serious complication of tracheostomy, often leading to a high mortality rate due to severe hemorrhagic shock [ ]. Promptly controlling bleeding and ensuring physiological stability are key to preventing the dangerous triad of hypothermia, acidosis, and coagulopathy [ ]. This case illustrates the potential complications from performing a percutaneous tracheotomy, especially in patients with complex vascular anatomy.
2
Case report
A 55-year-old female patient with past medical history of metastatic Anaplastic Hemangiopericytoma who was brought to the hospital for management of hemoptysis. She underwent intubation on arrival due to her altered mental status. She then underwent left phrenic artery and left bronchial artery embolization. After fourteen days, she was unable to be weaned off mechanical ventilation. The ICU team then performed a bedside percutaneous tracheostomy after examining the anterior neck with an ultrasound prior to the procedure. Ultrasound revealed engorged anterior jugular vein to the side, multiple thyroid cysts, and an innominate artery at the level of the sternal notch. During PCT, significant bleeding was noted and was tamponade by the introducer. Oral and Maxillofacial Surgery Service were consulted for concern of airway bleeding and vessel perforation. During the assessment, patient was initially hemodynamically stable. An introducer had been placed and kept in place. The patient was then taken emergently to the operating room for an emergent open surgical tracheostomy. The introducer kept in place, while a formal wound exploration and tracheotomy was performed to secure the airway first. The introducer did not injure anterior jugular vein and was noted to injure and side walling through innominate artery [ Fig. 1 ]. The innominate artery was dissected superior and inferior to the site of injury while the introducer was still in place. Upon removal of the introducer, a massive bleeding was encountered. The bleeding was controlled by closing the opening of the side wall by a hemostat and then using a large Ligaclip to close the sidewall of IA [ Fig. 2 ]. The remaining portion of the procedure was uncomplicated. There were no post operative neurologic changes or surgical site complications noted. Post operative chest x-ray confirmed the position of the trach tube [ Fig. 3 ]. Patient was later decannulated without any complications and discharged to a skilled nursing facility.
