Innominate Artery Rupture A Major Complication of Tracheal Surgery J. Deslauriers, M.D., R. J. Ginsberg, M.D., J. M. Nelems, M.D., a n d F. G. Pearson, M.D. ABSTRACT Innominate artery rupture is a life-threatening complication of tracheal reconstructive surgery. Early postoperative rupture of the innominate artery occurred in 8 of 100 consecutive patients undergoing tracheal resection and reconstruction (93, end-to-endanastomosis; 7, Marlex prosthesis). A premonitory transient hemoptysis occurred in 4 of the 8,patients. This sign may permit early diagnosis and effective treatment. When massive hemorrhage occurs, prompt arterial compression, control of the airway, and subsequent ligation of the artery may be lifesaving. Direct repair of the arterial defect is not recommended. If the innominate artery lies in direct contact with the suture line following primary anastomosis, soft tissue interposition is recommended.
M
assive hemorrhage from the innominate artery due to pressure erosion from a tracheostomy tube is a well-documented complication [2, 3, 5, 7, 9- 11, 13, 141. Few reports have appeared, however, of innominate artery erosion complicating tracheal resection and reconstruction by either a prosthesis or primary anastomosis [ l , 4 , 9 , 12, 151. There have been still fewer reports of patients successfully resuscitated following this complication; indeed, only 2 have been documented in the literature [6, 8, 9, 12, 151. This paper reviews our experience with 100 consecutive patients undergoing tracheal reconstruction in whom the complication of innominate artery rupture occurred in 8 instances. Three of these 8 patients were successfully resuscitated.
Clinical Material In 93 patients the tracheal defect was closed by end-to-end anastomosis, and innominate artery hemorrhage occurred in 4 instances (Table). Three of the 4 patients were saved by emergency compression of the bleeding artery and establishment of an airway, followed by median sternotomy and ligation of the innominate artery. The innominate artery is normally in contact with the anterior wall of the trachea at the level of the fifth or sixth tracheal cartilage and usually lies behind the upper part of the manubrium. In some patients, particularly young women, the artery crosses at a higher level and is still more intimately in contact with the underlying trachea, since both structures lie in the narrowest part of the thoracic outlet. Three of the 4 patients who developed innominate artery rupture following primary anastomosis were young women under 20 years of age. From the Division of Thoracic Surgery, Toronto General Hospital, Toronto Western Hospital, and the University of Toronto, Toronto, Ont., Canada. Presented at the Eleventh Annual Meeting of T h e Society of Thoracic Surgeons, Montreal, Que., Canada, Jan. 20-22, 1975. Address reprint requests to Dr. Pearson, Division of Thoracic Surgery, University Wing, Room 120, Toronto General Hospital, Toronto, Ont., Canada. VOL. 20, NO. 6, DECEMBER, 1975
671
DESLAURIERS ET AL. INNOMINATE ARTERY HEMORRHAGE FOLLOWING TRACHEAL RECONSTRUCTION
Patient's Age & Sex
Days Between Operation & Erosion
Premonitory Hemoptysis
Outcome
PRIMARY ANASTOMOSIS
19, F 47, F 19, F 13, F
Operative 11 2 2
No No No Yes ( 1 hr)
Alive & well Death Alive & well Alive with minimal weakness left arm
MARLEX PROSTHESIS
46, F 33, F
50, F 55, M
5
7
15 20 21
Yes (2 days) Yes ( 1 hr)
Death Death
Yes (6 days) No
Death Death
The remaining 7 patients had extensive tracheal defects that were reconstructed using a cylindrical prosthesis of heavy Marlex mesh. Innominate artery erosion occurred in 4 of these 7 patients, and none were successfully resuscitated (see the Table). Massive hemorrhage occurred within three weeks of reconstruction in all 4 patients and appeared to be the result of pressure erosion alone, since none of the patients had local sepsis or mediastinitis. In 4 of the 8 patients, massive hemorrhage was preceded by a transient episode of bright red hemoptysis. The interval between hemoptysis and massive bleeding varied from one hour to six days. In 1 patient, a portable chest roentgenogram obtained on the second postoperative day showed marked progressive widening of the mediastinum (Figure). Massive hemorrhage due to rupture of the artery occurred three hours after the roentgenogram was taken. Once massive hemorrhage had occurred, the picture was that of rapid exsanguination and asphyxia. The acute airway obstruction was due to either external tracheal compression by an expanding hematoma or actual rupture into the airway. The clinical course of these patients is illustrated by two case reports. PATIENT 1
A 13-year-old girl was admitted to Toronto General Hospital with a stricture of the upper mediastinal trachea, a complication of cuffed tracheostomy tube and assisted ventilation for respiratory failure due to the Guillain-Barre'syndrome. On December 8,197 1, a 2 cm segment of trachea was resected and continuity restored by primary anastomosis. A collar cervical incision provided adequate operative exposure. Interrupted sutures of 3-0 chromic catgut were used for the anastomosis. At the time of operation it was noted that the innominate artery lay directly over the anterior part of the completed anastomosis. Forty-eight hours after the operation she suddenly lost consciousness, be672
THE ANNALS OF THORACIC SURGERY
Innominate Artery Rupture
( A ) Portable chest roentgenogram obtained on the first postoperative day shows a normal superior mediastinum. ( B ) Portable chest roentgenogram obtained on the second postoperative day. Widening of the superior mediastinum Zr evident (arrows). Thzi radiogram was obtained three hours prior to clinical evidence of massive bleeding from the eroded innominate artery.
came cyanotic with obvious airway obstruction, and developed a rapidly expanding swelling in the neck. Fortunately, a resident was close by who made a correct provisional diagnosis of innominate artery rupture and, at the bedside, promptly opened the cervical incision with a penknife and secured control of the bleeding by digital compression of the artery against the manubrium. An airway was then established by opening the anterior part of the tracheal anastomosis and passing a rigid bronchoscope. With finger and bronchoscope in place, the patient was taken to the operating room. Through a median sternotomy the damaged segment of artery was excised, the divided ends were ligated, and the defect in the anterior part of the tracheal anastomosis was closed. There was no postoperative infection, and the tracheal anastomosis healed satisfactorily. She did develop mild left-sided hemiparesis, however, and still suffered mild minimal residual weakness in the left arm at follow-up four years after the episode. PATIENT 2
In April, 1965, a 33-year-old woman underwent laryngectomy and resection of almost the entire trachea for an extensive adenoid cystic carcinoma. T h e mediastinal trachea was reconstructed with a cylinder of heavy Marlex mesh, and the upper end of the prosthesis was sutured to the skin in the suprasternal notch as an end-tracheostomy. On her seventh postoperative day she suffered a brisk hemorrhage from the region of the tracheostomy stoma (approximately 600 ml during a ten-minute period). T h e bleeding stopped spontaneously, and she was immediately taken to the operating room where the wound was reexplored.
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DESLAURIERS
Er AL.
There was a small linear defect in the posterior wall of the innominate artery overlying one of the sutures in the Marlex prosthesis. T h e defect in the artery was sutured and a composite pedicle graft of anterior pericardial fat and pericardium was interposed between the artery and the prosthesis. Following this second operation she developed bilateral pneumonitis and required intermittent ventilation. Seven days following the second operation she suffered massive bleeding from a further innominate artery erosion and rupture, and died.
Comment If hemoptysis occurs in the postoperative period after a tracheal reconstructive operation, the possibility of innominate artery erosion should be foremost in the surgeon’s mind even though the hemoptysis may be transient and stop spontaneously. Immediate bronchoscopy is recommended to identify the origin of bleeding, not a difficult undertaking using the flexible bronchoscope. If an area of ulceration or granulation is identified as the bleeding site and is remote from the position of the innominate artery, then the surgeon may be reassured. If, however, the findings suggest the possibility of innominate artery erosion, the wound should be promptly explored. When massive hemorrhage occurs, treatment must be immediate and instituted at the bedside. T h e operative incision in the neck is opened, providing access for digital compression of the bleeding artery. At the same time, an airway must be established by rigid bronchoscopy. Although peroral bronchoscopy is preferable, this was not possible in Patient 1, in whom it was necessary to insert the scope through the anterior aspect of the tracheal anastomosis which had been exposed in the incision. Hypovolemia is managed by conventional measures. With finger and bronchoscope in position, the patient can then be transported to the operating room. Median sternotomy provides access for excising and ligating the ruptured segment of artery. In the 3 patients we saved, it was obvious that the circumstances permitting salvage were fortuitous. It is not likely that any patient with this complication will be successfully resuscitated. The emphasis, therefore, should be on prophylaxis. In any patient in whom the tracheal anastomosis ultimately lies in posterior relation to the innominate artery, some type of soft tissue interposition is recommended. Through a cervical incision, it is possible to interpose the superior pole or upper body of the thymus gland or a pedicle of sternothyroid muscle. If tracheal resection requires a median sternotomy, then a pericardial flap may be interposed as described by Arbulu and Thoms [l]. We would not recommend, however, that all patients have a median sternotomy and pericardial flap, since this would require an unnecessarily complex operative exposure in many cases. Although current techniques of tracheal surgery permit primary anastomosis following very extensive resections [4],there may still be an occasional patient in whom a prosthesis appears necessary. There is as yet no completely satisfactory tracheal prosthesis, and isolated reports of innominate artery erosion have occurred with almost every prosthesis used clinically in the past. Therefore, if a 674
T H E ANNALS OF THORACIC SURGERY
Innominate Artery Rupture prosthesis is employed, we suggest that the innominate artery circulation be maintained by a saphenous vein bypass graft and that the innominate artery itself be deliberately sacrificed. Although none of the patients reported in this series who were successfully salvaged by ligation of the innominate artery developed disabling neurological disability, the result of such ligation is not predictable in any given individual. Severe hemiparesis is possible, as is the “subclavian steal” of cerebral blood. For these reasons a concomitant bypass is recommended in any patient requiring sacrifice of the innominate artery.
References 1. Arbulu, A., and Thoms, N. W. Tracheal innominate artery fistula after repair of tracheal stenosis. J Thorac Cardiovasc Surg 67:963, 1974. 2. Biller, H. F., and Ebert, P. A. Innominate artery hemorrhage complicating tracheostomy. A n n Otol Rhino1 Laryngol 79:301, 1970. 3. Fardat, S. M., and Mehalic, T. F. Tracheoarterial fistula: A complication of tracheostomy in patients with brain stem injury. J Trauma 12:140, 1972. 4. Grillo, H. C. Surgery of the trachea. Cum Probl Surg July 1970. 5. Mathog, R. H., Kenan, P. D., and Hudson, W. R. Delayed massive hemorrhage following tracheostomy. Laryngoscope 8 1: 107, 197 1. 6. Mozersky, D. J., Barnes, R. W., S u m m e r , D. S., a n d Strandness, E., J r . Hemodynamics of innominate artery occlusion. A n n Surg 178: 123, 1973. 7. Myers, R. S., and Pilch, Y. H. Temporary control of tracheal innominate artery fistula. A n n Surg 170: 149, 1969. 8. Myers, W. O., Lawton, B. R., and Sautter, R. D. Letter to the Editor.J A M A 217:826, 1971. 9. Myers, W. O., Lawton, B. R., and Sautter, R. D. An operation for tracheal innominate artery fistula. Arch Surg 105:269, 1972. 10. Myers, W. O., Roy, M. Y., Lawton, B. R., and Sautter, R. D. Letter to the Editor.Arch Surg 108:749, 1974. 11. Reich, M. P., and Rosenkrantz, J. G. Fistula between innominate artery and trachea. Arch Surp 96:401. 1968. G., Donahoo, J. S., and Cameron, J. L. Tracheal innominate artery fistula 12. Revilla, i. after tracheal reconstruction. J Thorac Cardiovasc Surg 67~629,1974. 13. Silen, W., and Spieker, D. Fatal hemorrhage from the innominate artery after tracheostomy. A n n Surg 162:1005, 1965. 14. Utley, J. R., Singer, M. M., Roe, B. B., Fraser, D. G., and Dedo, H. H. Definitive management of innominate artery hemorrhage complicating tracheostomy. J A M A 220:577, 1972. 15. Webb, W. R. Discussion of Myers et al. [9].
Discussion DR. HERMES C. GRILLO (Boston, Mass.): This is certainly a very important paper from the Toronto General Hospital, important because there are probably more of these complications than we hear about. I have been startled to learn of rather large numbers of such complications in relatively small series, usually in a n anecdotal way as physicians pass through our hospital. I am not at all surprised at the high incidence of hemorrhage following prosthesis insertion. That has been the experience through the years with various prostheses, and continues to be. It is a common cause of death following prosthetic reconstruction. O n the other hand, the high incidence early after tracheal reconstruction and end-to-end anastomosis is not fully explained. T h e Toronto series shows a relatively low incidence. I n our own experience with end-to-end reconstructions at the Massachusetts General Hospital we have seen very little innominate artery hemorrhage postoperatively,
VOL. 20,
NO. 6, DECEMBER, 1975
675
DESLAURIERS E T AL. especially in the early period. It is a serious problem in laryngotracheal excisions and mediastinal tracheostomy, in which the problems are quite different. Among 139 consecutive patients undergoing surgical excision of stenosis with end-toend reconstruction there has been only 1 early postoperative innominate artery hemorrhage, and it occurred early in our series. I didn’t use a partial sternum-splitting incision in that patient, and I think the exposure was inadequate. A second instance of hemorrhage occurred late, after the patient had developed bilateral pneumonia and was on a ventilator for two weeks; that was really another problem. Therefore, I had thought that no special technical adjuncts are necessary. As I hear their report, however, I would agree with the essayists that tissue interposition is simple enough and might be a useful prophylactic measure. I should mention that 85 of my 139 patients had cuff stenoses, which means that the innominate artery was often involved in the inflammation and ended up lying directly on the tracheal anastomosis. I have no difference of opinion about management. The early bleeding warns you that it is time to get on with exploration. I don’t know quite what you meant by “ligation.” In 1 ligation in a patient who had had laryngotracheal excision, the field was septic and he bled again eight days later. Since then, when I have resected the innominate artery in other types of situations, I have used a double-layer suture closure rather than ligation, burying the stumps in healthy tissue remote from the septic area. In our 8 or 10 innominate artery resections we have been very lucky. All patients were aged 50 or under, and there were no neurological problems or “subclavian steals.” But we are very much aware that such problems could occur. DR. MANUELE. MACHADO-MACEDO (Lisbon, Portugal): In our Department of Cardiovascular Surgery at the Lisbon City Hospitals, we have reoperated on 2 patients who had previously undergone insufficient tracheal resection for benign stricture after prolonged assisted respiration. The first was a young woman of 18 who, three weeks after the first operation, showed increasing signs of restenosis. After a period of repeated bronchoscopies and dilations we decided to resect the new stricture. We used a collar incision extended downward with sternotomy to the fourth segment. The aorta and innominate artery branched off much more to the left than normal and were extremely adherent to the trachea. The arch of the aorta, which was really paper-thin, was ruptured; with intermittent clamping we were able to reconstruct it by direct suture. The innominate artery was freed and suspended with a sling, which actually cut through the artery. The aortic arch was tangentially clamped and the orifice of the innominate artery was sutured. Flow was reestablished by anastomosing the artery to the ascending aorta at a slightly lower level, interposing a segment of Dacron tube. The result was excellent. I would like to stress the point that reoperation should really be avoided by resecting enough trachea to have a good anastomosis initially. DR. WILLIAM E. NEVILLE(Newark, N.J.): We have had 1 fatal innominate artery erosion following prosthetic replacement of the trachea because of an error in technique. I realized that since the distal suture anastomosis was directly behind the innominate artery, the artery might erode. For this reason I wrapped the suture line with Teflon felt, which did not prevent fatal erosion of the artery. One cannot fault the prosthesis for this catastrophic occurrence since it also can happen following a primary anastomosis, as described by Dr. Deslauriers. Over the past few years we have mobilized a long flap of pericardium and wrapped it around the anastomotic area. In addition, we believe it is essential that the innominate artery or the aorta be wrapped with a Dacron arterial graft when the suture line abuts it. Following this, we interpose Teflon felt between the Dacron graft around the artery and the pericardium circumventing the suture line. We have had no problems with arterial erosion since adopting this technique. The tracheal anastomosis lies adjacent to a large artery only when the operation has to be performed through a cervical incision and a median sternotomy. When tracheal resection is done through a right thoracotomy, all the suture lines are behind the soft, compressible superior vena cava and left atrium, and there is no danger of a fatal erosion.
676
T H E ANNALS OF THORACIC SURGERY
Innominate Artery Rupture DR.DARRELL D. MUNRO(Montreal, Que., Canada): I would like to verify the authors’ .findings and commend them for bringing this complication to our attention. Innominate artery hemorrhage resulted in the death of the following patient. A 26-year-old woman with a primary adenocystic carcinoma involving most of the entire length of the trachea was originally treated for three years for asthma. In 1964 we improvised an artificial trachea utilizing Ivalon sheets with reinforcing nylon cording and resected her entire trachea from three rings above the carina to two rings below the cricoid cartilage. She returned to New Brunswick with a normal voice and resumed the duties of a long-distance telephone operator. Six months later, however, her problems resumed. From then on it was a continuous struggle with her airway. She required eleven separate hospital admissions in Montreal with one major resection procedure: a tracheostomy through the artificial trachea, which was eventually replaced with a Marlex mesh prosthesis. She underwent thirty-one bronchoscopies for fulguration and removal of granulation tissue. She finally died in New Brunswick with exsanguinating hemorrhage and resulting asphyxiation, three years two months following the original resection and entire replacement of her trachea. I can only conclude that prosthetic replacement in most of our hands is not a feasible project at the present time. Dr. Neville has just refuted that. However, we support the authors’ verification of this complication. We have no experience with complications of tracheal section and end-to-end anastomosis, but our series is small. DR.DESLAURIERS: To answer Dr. Grillo’s question on the arterial ligation, we also use a double layer of silk to oversew the arterial stump. We agree that with cuff stenoses the innominate artery is often markedly adherent to the anterior wall of the trachea, making it very easy to damage during operation when the traumatized artery is dissected and then retracted. Dr. Macedo’s comments confirm our findings. First of all, he had a very young woman, 18 years of age, and we have noticed that in these patients the innominate artery lies quite high in the neck. We agree that if the artery is torn at the initial operation, it should be divided and bypassed at that time rather than waiting for further hemorrhage to occur. To Dr. Neville’s comments on prosthetic replacement of the trachea I would add that if a rigid prosthesis is used, because of the cohtinuous friction between the artery and the prosthesis, we would ligate the innominate artery and bypass it again at the initial operation. Wrapping the artery with prosthetic materials certainly is very helpful, but if the field gets infected for any reason, it would be a major problem. Dr. Munro has discussed a patient who suffered a fatal innominate artery hemorrhage following Marlex replacement. We have also found the incidence of hemorrhage to be very high with this type of prosthesis; in our experience it represents about 50% of all innominate artery hemorrhages. We recommend bypassing the artery at the time of the initial operation.
VOL. 20, NO. 6, DECEMBER, 1975
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M
assive hemorrhage from the innominate artery due to pressure erosion from a tracheostomy tube is a well-documented complication [2, 3, 5, 7, 9- 11, 13, 141. Few reports have appeared, however, of innominate artery erosion complicating tracheal resection and reconstruction by either a prosthesis or primary anastomosis [ l , 4 , 9 , 12, 151. There have been still fewer reports of patients successfully resuscitated following this complication; indeed, only 2 have been documented in the literature [6, 8, 9, 12, 151. This paper reviews our experience with 100 consecutive patients undergoing tracheal reconstruction in whom the complication of innominate artery rupture occurred in 8 instances. Three of these 8 patients were successfully resuscitated.
Clinical Material In 93 patients the tracheal defect was closed by end-to-end anastomosis, and innominate artery hemorrhage occurred in 4 instances (Table). Three of the 4 patients were saved by emergency compression of the bleeding artery and establishment of an airway, followed by median sternotomy and ligation of the innominate artery. The innominate artery is normally in contact with the anterior wall of the trachea at the level of the fifth or sixth tracheal cartilage and usually lies behind the upper part of the manubrium. In some patients, particularly young women, the artery crosses at a higher level and is still more intimately in contact with the underlying trachea, since both structures lie in the narrowest part of the thoracic outlet. Three of the 4 patients who developed innominate artery rupture following primary anastomosis were young women under 20 years of age. From the Division of Thoracic Surgery, Toronto General Hospital, Toronto Western Hospital, and the University of Toronto, Toronto, Ont., Canada. Presented at the Eleventh Annual Meeting of T h e Society of Thoracic Surgeons, Montreal, Que., Canada, Jan. 20-22, 1975. Address reprint requests to Dr. Pearson, Division of Thoracic Surgery, University Wing, Room 120, Toronto General Hospital, Toronto, Ont., Canada. VOL. 20, NO. 6, DECEMBER, 1975
671
DESLAURIERS ET AL. INNOMINATE ARTERY HEMORRHAGE FOLLOWING TRACHEAL RECONSTRUCTION
Patient's Age & Sex
Days Between Operation & Erosion
Premonitory Hemoptysis
Outcome
PRIMARY ANASTOMOSIS
19, F 47, F 19, F 13, F
Operative 11 2 2
No No No Yes ( 1 hr)
Alive & well Death Alive & well Alive with minimal weakness left arm
MARLEX PROSTHESIS
46, F 33, F
50, F 55, M
5
7
15 20 21
Yes (2 days) Yes ( 1 hr)
Death Death
Yes (6 days) No
Death Death
The remaining 7 patients had extensive tracheal defects that were reconstructed using a cylindrical prosthesis of heavy Marlex mesh. Innominate artery erosion occurred in 4 of these 7 patients, and none were successfully resuscitated (see the Table). Massive hemorrhage occurred within three weeks of reconstruction in all 4 patients and appeared to be the result of pressure erosion alone, since none of the patients had local sepsis or mediastinitis. In 4 of the 8 patients, massive hemorrhage was preceded by a transient episode of bright red hemoptysis. The interval between hemoptysis and massive bleeding varied from one hour to six days. In 1 patient, a portable chest roentgenogram obtained on the second postoperative day showed marked progressive widening of the mediastinum (Figure). Massive hemorrhage due to rupture of the artery occurred three hours after the roentgenogram was taken. Once massive hemorrhage had occurred, the picture was that of rapid exsanguination and asphyxia. The acute airway obstruction was due to either external tracheal compression by an expanding hematoma or actual rupture into the airway. The clinical course of these patients is illustrated by two case reports. PATIENT 1
A 13-year-old girl was admitted to Toronto General Hospital with a stricture of the upper mediastinal trachea, a complication of cuffed tracheostomy tube and assisted ventilation for respiratory failure due to the Guillain-Barre'syndrome. On December 8,197 1, a 2 cm segment of trachea was resected and continuity restored by primary anastomosis. A collar cervical incision provided adequate operative exposure. Interrupted sutures of 3-0 chromic catgut were used for the anastomosis. At the time of operation it was noted that the innominate artery lay directly over the anterior part of the completed anastomosis. Forty-eight hours after the operation she suddenly lost consciousness, be672
THE ANNALS OF THORACIC SURGERY
Innominate Artery Rupture
( A ) Portable chest roentgenogram obtained on the first postoperative day shows a normal superior mediastinum. ( B ) Portable chest roentgenogram obtained on the second postoperative day. Widening of the superior mediastinum Zr evident (arrows). Thzi radiogram was obtained three hours prior to clinical evidence of massive bleeding from the eroded innominate artery.
came cyanotic with obvious airway obstruction, and developed a rapidly expanding swelling in the neck. Fortunately, a resident was close by who made a correct provisional diagnosis of innominate artery rupture and, at the bedside, promptly opened the cervical incision with a penknife and secured control of the bleeding by digital compression of the artery against the manubrium. An airway was then established by opening the anterior part of the tracheal anastomosis and passing a rigid bronchoscope. With finger and bronchoscope in place, the patient was taken to the operating room. Through a median sternotomy the damaged segment of artery was excised, the divided ends were ligated, and the defect in the anterior part of the tracheal anastomosis was closed. There was no postoperative infection, and the tracheal anastomosis healed satisfactorily. She did develop mild left-sided hemiparesis, however, and still suffered mild minimal residual weakness in the left arm at follow-up four years after the episode. PATIENT 2
In April, 1965, a 33-year-old woman underwent laryngectomy and resection of almost the entire trachea for an extensive adenoid cystic carcinoma. T h e mediastinal trachea was reconstructed with a cylinder of heavy Marlex mesh, and the upper end of the prosthesis was sutured to the skin in the suprasternal notch as an end-tracheostomy. On her seventh postoperative day she suffered a brisk hemorrhage from the region of the tracheostomy stoma (approximately 600 ml during a ten-minute period). T h e bleeding stopped spontaneously, and she was immediately taken to the operating room where the wound was reexplored.
VOL. 20, NO. 6, DECEMBER, 1975
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DESLAURIERS
Er AL.
There was a small linear defect in the posterior wall of the innominate artery overlying one of the sutures in the Marlex prosthesis. T h e defect in the artery was sutured and a composite pedicle graft of anterior pericardial fat and pericardium was interposed between the artery and the prosthesis. Following this second operation she developed bilateral pneumonitis and required intermittent ventilation. Seven days following the second operation she suffered massive bleeding from a further innominate artery erosion and rupture, and died.
Comment If hemoptysis occurs in the postoperative period after a tracheal reconstructive operation, the possibility of innominate artery erosion should be foremost in the surgeon’s mind even though the hemoptysis may be transient and stop spontaneously. Immediate bronchoscopy is recommended to identify the origin of bleeding, not a difficult undertaking using the flexible bronchoscope. If an area of ulceration or granulation is identified as the bleeding site and is remote from the position of the innominate artery, then the surgeon may be reassured. If, however, the findings suggest the possibility of innominate artery erosion, the wound should be promptly explored. When massive hemorrhage occurs, treatment must be immediate and instituted at the bedside. T h e operative incision in the neck is opened, providing access for digital compression of the bleeding artery. At the same time, an airway must be established by rigid bronchoscopy. Although peroral bronchoscopy is preferable, this was not possible in Patient 1, in whom it was necessary to insert the scope through the anterior aspect of the tracheal anastomosis which had been exposed in the incision. Hypovolemia is managed by conventional measures. With finger and bronchoscope in position, the patient can then be transported to the operating room. Median sternotomy provides access for excising and ligating the ruptured segment of artery. In the 3 patients we saved, it was obvious that the circumstances permitting salvage were fortuitous. It is not likely that any patient with this complication will be successfully resuscitated. The emphasis, therefore, should be on prophylaxis. In any patient in whom the tracheal anastomosis ultimately lies in posterior relation to the innominate artery, some type of soft tissue interposition is recommended. Through a cervical incision, it is possible to interpose the superior pole or upper body of the thymus gland or a pedicle of sternothyroid muscle. If tracheal resection requires a median sternotomy, then a pericardial flap may be interposed as described by Arbulu and Thoms [l]. We would not recommend, however, that all patients have a median sternotomy and pericardial flap, since this would require an unnecessarily complex operative exposure in many cases. Although current techniques of tracheal surgery permit primary anastomosis following very extensive resections [4],there may still be an occasional patient in whom a prosthesis appears necessary. There is as yet no completely satisfactory tracheal prosthesis, and isolated reports of innominate artery erosion have occurred with almost every prosthesis used clinically in the past. Therefore, if a 674
T H E ANNALS OF THORACIC SURGERY
Innominate Artery Rupture prosthesis is employed, we suggest that the innominate artery circulation be maintained by a saphenous vein bypass graft and that the innominate artery itself be deliberately sacrificed. Although none of the patients reported in this series who were successfully salvaged by ligation of the innominate artery developed disabling neurological disability, the result of such ligation is not predictable in any given individual. Severe hemiparesis is possible, as is the “subclavian steal” of cerebral blood. For these reasons a concomitant bypass is recommended in any patient requiring sacrifice of the innominate artery.
References 1. Arbulu, A., and Thoms, N. W. Tracheal innominate artery fistula after repair of tracheal stenosis. J Thorac Cardiovasc Surg 67:963, 1974. 2. Biller, H. F., and Ebert, P. A. Innominate artery hemorrhage complicating tracheostomy. A n n Otol Rhino1 Laryngol 79:301, 1970. 3. Fardat, S. M., and Mehalic, T. F. Tracheoarterial fistula: A complication of tracheostomy in patients with brain stem injury. J Trauma 12:140, 1972. 4. Grillo, H. C. Surgery of the trachea. Cum Probl Surg July 1970. 5. Mathog, R. H., Kenan, P. D., and Hudson, W. R. Delayed massive hemorrhage following tracheostomy. Laryngoscope 8 1: 107, 197 1. 6. Mozersky, D. J., Barnes, R. W., S u m m e r , D. S., a n d Strandness, E., J r . Hemodynamics of innominate artery occlusion. A n n Surg 178: 123, 1973. 7. Myers, R. S., and Pilch, Y. H. Temporary control of tracheal innominate artery fistula. A n n Surg 170: 149, 1969. 8. Myers, W. O., Lawton, B. R., and Sautter, R. D. Letter to the Editor.J A M A 217:826, 1971. 9. Myers, W. O., Lawton, B. R., and Sautter, R. D. An operation for tracheal innominate artery fistula. Arch Surg 105:269, 1972. 10. Myers, W. O., Roy, M. Y., Lawton, B. R., and Sautter, R. D. Letter to the Editor.Arch Surg 108:749, 1974. 11. Reich, M. P., and Rosenkrantz, J. G. Fistula between innominate artery and trachea. Arch Surp 96:401. 1968. G., Donahoo, J. S., and Cameron, J. L. Tracheal innominate artery fistula 12. Revilla, i. after tracheal reconstruction. J Thorac Cardiovasc Surg 67~629,1974. 13. Silen, W., and Spieker, D. Fatal hemorrhage from the innominate artery after tracheostomy. A n n Surg 162:1005, 1965. 14. Utley, J. R., Singer, M. M., Roe, B. B., Fraser, D. G., and Dedo, H. H. Definitive management of innominate artery hemorrhage complicating tracheostomy. J A M A 220:577, 1972. 15. Webb, W. R. Discussion of Myers et al. [9].
Discussion DR. HERMES C. GRILLO (Boston, Mass.): This is certainly a very important paper from the Toronto General Hospital, important because there are probably more of these complications than we hear about. I have been startled to learn of rather large numbers of such complications in relatively small series, usually in a n anecdotal way as physicians pass through our hospital. I am not at all surprised at the high incidence of hemorrhage following prosthesis insertion. That has been the experience through the years with various prostheses, and continues to be. It is a common cause of death following prosthetic reconstruction. O n the other hand, the high incidence early after tracheal reconstruction and end-to-end anastomosis is not fully explained. T h e Toronto series shows a relatively low incidence. I n our own experience with end-to-end reconstructions at the Massachusetts General Hospital we have seen very little innominate artery hemorrhage postoperatively,
VOL. 20,
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DESLAURIERS E T AL. especially in the early period. It is a serious problem in laryngotracheal excisions and mediastinal tracheostomy, in which the problems are quite different. Among 139 consecutive patients undergoing surgical excision of stenosis with end-toend reconstruction there has been only 1 early postoperative innominate artery hemorrhage, and it occurred early in our series. I didn’t use a partial sternum-splitting incision in that patient, and I think the exposure was inadequate. A second instance of hemorrhage occurred late, after the patient had developed bilateral pneumonia and was on a ventilator for two weeks; that was really another problem. Therefore, I had thought that no special technical adjuncts are necessary. As I hear their report, however, I would agree with the essayists that tissue interposition is simple enough and might be a useful prophylactic measure. I should mention that 85 of my 139 patients had cuff stenoses, which means that the innominate artery was often involved in the inflammation and ended up lying directly on the tracheal anastomosis. I have no difference of opinion about management. The early bleeding warns you that it is time to get on with exploration. I don’t know quite what you meant by “ligation.” In 1 ligation in a patient who had had laryngotracheal excision, the field was septic and he bled again eight days later. Since then, when I have resected the innominate artery in other types of situations, I have used a double-layer suture closure rather than ligation, burying the stumps in healthy tissue remote from the septic area. In our 8 or 10 innominate artery resections we have been very lucky. All patients were aged 50 or under, and there were no neurological problems or “subclavian steals.” But we are very much aware that such problems could occur. DR. MANUELE. MACHADO-MACEDO (Lisbon, Portugal): In our Department of Cardiovascular Surgery at the Lisbon City Hospitals, we have reoperated on 2 patients who had previously undergone insufficient tracheal resection for benign stricture after prolonged assisted respiration. The first was a young woman of 18 who, three weeks after the first operation, showed increasing signs of restenosis. After a period of repeated bronchoscopies and dilations we decided to resect the new stricture. We used a collar incision extended downward with sternotomy to the fourth segment. The aorta and innominate artery branched off much more to the left than normal and were extremely adherent to the trachea. The arch of the aorta, which was really paper-thin, was ruptured; with intermittent clamping we were able to reconstruct it by direct suture. The innominate artery was freed and suspended with a sling, which actually cut through the artery. The aortic arch was tangentially clamped and the orifice of the innominate artery was sutured. Flow was reestablished by anastomosing the artery to the ascending aorta at a slightly lower level, interposing a segment of Dacron tube. The result was excellent. I would like to stress the point that reoperation should really be avoided by resecting enough trachea to have a good anastomosis initially. DR. WILLIAM E. NEVILLE(Newark, N.J.): We have had 1 fatal innominate artery erosion following prosthetic replacement of the trachea because of an error in technique. I realized that since the distal suture anastomosis was directly behind the innominate artery, the artery might erode. For this reason I wrapped the suture line with Teflon felt, which did not prevent fatal erosion of the artery. One cannot fault the prosthesis for this catastrophic occurrence since it also can happen following a primary anastomosis, as described by Dr. Deslauriers. Over the past few years we have mobilized a long flap of pericardium and wrapped it around the anastomotic area. In addition, we believe it is essential that the innominate artery or the aorta be wrapped with a Dacron arterial graft when the suture line abuts it. Following this, we interpose Teflon felt between the Dacron graft around the artery and the pericardium circumventing the suture line. We have had no problems with arterial erosion since adopting this technique. The tracheal anastomosis lies adjacent to a large artery only when the operation has to be performed through a cervical incision and a median sternotomy. When tracheal resection is done through a right thoracotomy, all the suture lines are behind the soft, compressible superior vena cava and left atrium, and there is no danger of a fatal erosion.
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T H E ANNALS OF THORACIC SURGERY
Innominate Artery Rupture DR.DARRELL D. MUNRO(Montreal, Que., Canada): I would like to verify the authors’ .findings and commend them for bringing this complication to our attention. Innominate artery hemorrhage resulted in the death of the following patient. A 26-year-old woman with a primary adenocystic carcinoma involving most of the entire length of the trachea was originally treated for three years for asthma. In 1964 we improvised an artificial trachea utilizing Ivalon sheets with reinforcing nylon cording and resected her entire trachea from three rings above the carina to two rings below the cricoid cartilage. She returned to New Brunswick with a normal voice and resumed the duties of a long-distance telephone operator. Six months later, however, her problems resumed. From then on it was a continuous struggle with her airway. She required eleven separate hospital admissions in Montreal with one major resection procedure: a tracheostomy through the artificial trachea, which was eventually replaced with a Marlex mesh prosthesis. She underwent thirty-one bronchoscopies for fulguration and removal of granulation tissue. She finally died in New Brunswick with exsanguinating hemorrhage and resulting asphyxiation, three years two months following the original resection and entire replacement of her trachea. I can only conclude that prosthetic replacement in most of our hands is not a feasible project at the present time. Dr. Neville has just refuted that. However, we support the authors’ verification of this complication. We have no experience with complications of tracheal section and end-to-end anastomosis, but our series is small. DR.DESLAURIERS: To answer Dr. Grillo’s question on the arterial ligation, we also use a double layer of silk to oversew the arterial stump. We agree that with cuff stenoses the innominate artery is often markedly adherent to the anterior wall of the trachea, making it very easy to damage during operation when the traumatized artery is dissected and then retracted. Dr. Macedo’s comments confirm our findings. First of all, he had a very young woman, 18 years of age, and we have noticed that in these patients the innominate artery lies quite high in the neck. We agree that if the artery is torn at the initial operation, it should be divided and bypassed at that time rather than waiting for further hemorrhage to occur. To Dr. Neville’s comments on prosthetic replacement of the trachea I would add that if a rigid prosthesis is used, because of the cohtinuous friction between the artery and the prosthesis, we would ligate the innominate artery and bypass it again at the initial operation. Wrapping the artery with prosthetic materials certainly is very helpful, but if the field gets infected for any reason, it would be a major problem. Dr. Munro has discussed a patient who suffered a fatal innominate artery hemorrhage following Marlex replacement. We have also found the incidence of hemorrhage to be very high with this type of prosthesis; in our experience it represents about 50% of all innominate artery hemorrhages. We recommend bypassing the artery at the time of the initial operation.
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