Case Study
Tracheoinnominate fistula: a rare acute complication of penetrating neck injury
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(4) 478–480 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314540918 aan.sagepub.com
Alena Kulyapina1, Dolores Pe´rez Dı´az2, Teresa Sanchez Rodrı´guez2 and Fernando Turegano Fuentes2
Abstract Penetrating injuries in the base of the neck are considered to be the most dangerous due to the potential combination of vascular and intrathoracic lesions. We describe an extremely rare case of combined injury of the trachea and innominate artery, which resulted in formation of a traumatic acute tracheoinnominate fistula. Previously, these fistulas have been described as an iatrogenic complication of tracheostomy, presenting with massive peristomal bleed or hemoptysis. This case demonstrates that a combination of lesions to vital anatomical structures in the neck can change their clinical presentation, making them extremely difficult to diagnose.
Keywords Blood vessels, brachiocephalic trunk, neck injuries, trachea, vascular fistula, wounds, penetrating
Introduction Penetrating neck injuries remain challenging because of the important structures in a small area, and injury to any of these structures may not be readily apparent. Injuries to the base of the neck (zone I) are considered to be the most dangerous due to the potential combination of vascular and intrathoracic lesions. We describe a case of tracheoinnominate fistula (TIF) formation from a combined injury to the trachea and brachiocephalic trunk, resulting from a stab wound in the neck. TIF is a well-known life-threatening complication after tracheostomy, which to the best of our knowledge has not been reported as an acute manifestation of a penetrating neck wound.
Case report A 62-year-old man with a knife stab wound in zone I of the left neck was brought to the emergency department. A stab wound of approximately 2 cm in the left neck was observed just above the manubrium. On arrival, the patient was stable. Chest radiography showed widening of the mediastinum. Urgent computed tomography angiography revealed an extensive left lateral cervical hematoma due to disruption of the
brachiocephalic trunk with formation of a 12-mm pseudoaneurysm (Figure 1). While in the computed tomography room, the patient suffered hypovolemic shock with severe hemoptysis. He was immediately intubated and brought to the operating room. An urgent median sternotomy with neck extension was performed, the hematoma was evacuated, and an active hemorrhage at the level of the brachiocephalic trunk due to the section of two-thirds of this vessel was discovered. A small laceration of 1.5 mm in the anterior wall of the trachea adjacent to hematoma was also detected. The brachiocephalic trunk was directly repaired, achieving arrest of the bleeding and maintaining the integrity of the vessel (Figure 2). No bypass was applied. The anterior wall of the trachea was primarily repaired. Following the surgical intervention, the patient required mechanical 1 Department of Maxillofacial Surgery, Gregorio Maran˜o´n General University Hospital, Madrid, Spain 2 Department of General Surgery, Gregorio Maran˜o´n General University Hospital, Madrid, Spain
Corresponding author: Alena Kulyapina, Department of Maxillofacial Surgery, Gregorio Maran˜on General University Hospital, C/Doctor Esquerdo 46, Madrid, Spain. Email: [email protected]
Downloaded from aan.sagepub.com at Mount Royal University on June 7, 2015
Kulyapina et al.
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Figure 1. Computed tomography angiography: red arrow shows traumatic disruption of the brachiocephalic trunk.
Figure 2. Intraoperative view of the brachiocephalic trunk repair. Black arrow shows disruption of the brachiocephalic trunk.
ventilation for 72 h. Fiberoptic bronchoscopy was performed on the second postoperative day, confirming the integrity of the upper airways. The patient’s recovery was uneventful.
Discussion The close proximity of vital anatomical structures of the neck and thorax explains the possibility of combined complex lesions, especially in the case of zone I neck trauma. In neck injuries, the frequencies of damage to vital structures are: large vessels 44.1%, larynx-trachea 13.6%, pharynx-esophagus 5.0%, and spinal cord 8.4%.1 Penetrating innominate artery injury is rarely encountered clinically because of the
small length of the vessel, the protection of the rib cage, and the lethal nature of such injuries. It is estimated that 30% to 80% of patients with tracheal or bronchial injuries and 71% of those with major vascular injuries of the thoracic outlet expire before reaching the hospital.2 Clinical signs of tracheal injury are subcutaneous crepitus, reparatory compromise, and bubbling from the wound.3 Pneumothorax and pneumomediastinum are common chest radiography findings. Expanding hematoma of the neck suggests a vascular injury. A widened mediastinum and hemothorax are found frequently in innominate artery lesions. Management of tracheal injury is based on achievement of a secure and patent airway. All patients with airway injuries should be intubated over a flexible bronchoscope. The cuff of the tube should be placed distal to the site of injury. No bronchoscopy was performed in this case due to the instability of the patient and the combined vascular injury to be addressed. In this particular case of penetrating neck wound, no signs of tracheal rupture such as subcutaneous emphysema or pneumothorax were observed on admission. A delayed massive hemoptysis was the sudden manifestation of acute TIF. This atypical presentation of a neck stab wound can be explained by the following model: the stab wound in zone I of the left neck had an inferomedial direction, producing laceration of the anterior tracheal wall and brachiocephalic artery. The compartmental pressure of the increasing neck hematoma prevented air leak from the tracheal laceration, which could explain the absence of subcutaneous emphysema. This hematoma, due to rupture of a major vessel, drained spontaneously through the tracheal wall laceration with TIF formation, producing typical symptoms of TIF: massive devastating hemoptysis and hypovolemic shock. TIF is a well-known iatrogenic complication of tracheostomy. One case of iatrogenic TIF formation was described as a result of migration of a Kirschner wire.4 No data on acute TIF resulting from penetrating neck trauma was found in the literature. TIF has a reported incidence of 0.6%–0.7% in all tracheostomies. It presents with peristomal bleeding or hemoptysis which can be fatal if treatment is not instituted immediately. The mechanism of injury is necrosis caused by the pressure of the tracheostomy tube itself or the cuff, with erosion of the tracheal cartilage and the innominate artery. This case confirms that penetrating zone I neck injuries can result in life-threatening lesions to vital anatomical structures. The combination of these lesions can change their clinical presentation, making them extremely difficult to diagnose and decide further management.
Downloaded from aan.sagepub.com at Mount Royal University on June 7, 2015
480
Asian Cardiovascular & Thoracic Annals 23(4)
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Carducci B, Lowe RA and Dalsey W. Penetrating neck trauma: consensus and controversies. Ann Emerg Med 1986; 15: 208–215.
2. Blattman SB, Landis GS, Knight M, Panetta TF, Sclafani SJ and Burack JH. Combined endovascular and open repair of a penetrating innominate artery and tracheal injury. Ann Thorac Surg 2002; 74: 237–239. 3. Bell RB, Osborn T, Dierks EJ, Potter BE and Long WB. Management of penetrating neck injuries: a new paradigm for civilian trauma. J Oral Maxillofac Surg 2007; 65: 691–705. 4. Wu YH, Lai CH, Luo CY and Tseng YL. Tracheoinnominate artery fistula caused by migration of a Kirschner wire. Eur J Cardiothorac Surg 2009; 36: 214–216.
Downloaded from aan.sagepub.com at Mount Royal University on June 7, 2015
Tracheoinnominate fistula: a rare acute complication of penetrating neck injury
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(4) 478–480 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314540918 aan.sagepub.com
Alena Kulyapina1, Dolores Pe´rez Dı´az2, Teresa Sanchez Rodrı´guez2 and Fernando Turegano Fuentes2
Abstract Penetrating injuries in the base of the neck are considered to be the most dangerous due to the potential combination of vascular and intrathoracic lesions. We describe an extremely rare case of combined injury of the trachea and innominate artery, which resulted in formation of a traumatic acute tracheoinnominate fistula. Previously, these fistulas have been described as an iatrogenic complication of tracheostomy, presenting with massive peristomal bleed or hemoptysis. This case demonstrates that a combination of lesions to vital anatomical structures in the neck can change their clinical presentation, making them extremely difficult to diagnose.
Keywords Blood vessels, brachiocephalic trunk, neck injuries, trachea, vascular fistula, wounds, penetrating
Introduction Penetrating neck injuries remain challenging because of the important structures in a small area, and injury to any of these structures may not be readily apparent. Injuries to the base of the neck (zone I) are considered to be the most dangerous due to the potential combination of vascular and intrathoracic lesions. We describe a case of tracheoinnominate fistula (TIF) formation from a combined injury to the trachea and brachiocephalic trunk, resulting from a stab wound in the neck. TIF is a well-known life-threatening complication after tracheostomy, which to the best of our knowledge has not been reported as an acute manifestation of a penetrating neck wound.
Case report A 62-year-old man with a knife stab wound in zone I of the left neck was brought to the emergency department. A stab wound of approximately 2 cm in the left neck was observed just above the manubrium. On arrival, the patient was stable. Chest radiography showed widening of the mediastinum. Urgent computed tomography angiography revealed an extensive left lateral cervical hematoma due to disruption of the
brachiocephalic trunk with formation of a 12-mm pseudoaneurysm (Figure 1). While in the computed tomography room, the patient suffered hypovolemic shock with severe hemoptysis. He was immediately intubated and brought to the operating room. An urgent median sternotomy with neck extension was performed, the hematoma was evacuated, and an active hemorrhage at the level of the brachiocephalic trunk due to the section of two-thirds of this vessel was discovered. A small laceration of 1.5 mm in the anterior wall of the trachea adjacent to hematoma was also detected. The brachiocephalic trunk was directly repaired, achieving arrest of the bleeding and maintaining the integrity of the vessel (Figure 2). No bypass was applied. The anterior wall of the trachea was primarily repaired. Following the surgical intervention, the patient required mechanical 1 Department of Maxillofacial Surgery, Gregorio Maran˜o´n General University Hospital, Madrid, Spain 2 Department of General Surgery, Gregorio Maran˜o´n General University Hospital, Madrid, Spain
Corresponding author: Alena Kulyapina, Department of Maxillofacial Surgery, Gregorio Maran˜on General University Hospital, C/Doctor Esquerdo 46, Madrid, Spain. Email: [email protected]
Downloaded from aan.sagepub.com at Mount Royal University on June 7, 2015
Kulyapina et al.
479
Figure 1. Computed tomography angiography: red arrow shows traumatic disruption of the brachiocephalic trunk.
Figure 2. Intraoperative view of the brachiocephalic trunk repair. Black arrow shows disruption of the brachiocephalic trunk.
ventilation for 72 h. Fiberoptic bronchoscopy was performed on the second postoperative day, confirming the integrity of the upper airways. The patient’s recovery was uneventful.
Discussion The close proximity of vital anatomical structures of the neck and thorax explains the possibility of combined complex lesions, especially in the case of zone I neck trauma. In neck injuries, the frequencies of damage to vital structures are: large vessels 44.1%, larynx-trachea 13.6%, pharynx-esophagus 5.0%, and spinal cord 8.4%.1 Penetrating innominate artery injury is rarely encountered clinically because of the
small length of the vessel, the protection of the rib cage, and the lethal nature of such injuries. It is estimated that 30% to 80% of patients with tracheal or bronchial injuries and 71% of those with major vascular injuries of the thoracic outlet expire before reaching the hospital.2 Clinical signs of tracheal injury are subcutaneous crepitus, reparatory compromise, and bubbling from the wound.3 Pneumothorax and pneumomediastinum are common chest radiography findings. Expanding hematoma of the neck suggests a vascular injury. A widened mediastinum and hemothorax are found frequently in innominate artery lesions. Management of tracheal injury is based on achievement of a secure and patent airway. All patients with airway injuries should be intubated over a flexible bronchoscope. The cuff of the tube should be placed distal to the site of injury. No bronchoscopy was performed in this case due to the instability of the patient and the combined vascular injury to be addressed. In this particular case of penetrating neck wound, no signs of tracheal rupture such as subcutaneous emphysema or pneumothorax were observed on admission. A delayed massive hemoptysis was the sudden manifestation of acute TIF. This atypical presentation of a neck stab wound can be explained by the following model: the stab wound in zone I of the left neck had an inferomedial direction, producing laceration of the anterior tracheal wall and brachiocephalic artery. The compartmental pressure of the increasing neck hematoma prevented air leak from the tracheal laceration, which could explain the absence of subcutaneous emphysema. This hematoma, due to rupture of a major vessel, drained spontaneously through the tracheal wall laceration with TIF formation, producing typical symptoms of TIF: massive devastating hemoptysis and hypovolemic shock. TIF is a well-known iatrogenic complication of tracheostomy. One case of iatrogenic TIF formation was described as a result of migration of a Kirschner wire.4 No data on acute TIF resulting from penetrating neck trauma was found in the literature. TIF has a reported incidence of 0.6%–0.7% in all tracheostomies. It presents with peristomal bleeding or hemoptysis which can be fatal if treatment is not instituted immediately. The mechanism of injury is necrosis caused by the pressure of the tracheostomy tube itself or the cuff, with erosion of the tracheal cartilage and the innominate artery. This case confirms that penetrating zone I neck injuries can result in life-threatening lesions to vital anatomical structures. The combination of these lesions can change their clinical presentation, making them extremely difficult to diagnose and decide further management.
Downloaded from aan.sagepub.com at Mount Royal University on June 7, 2015
480
Asian Cardiovascular & Thoracic Annals 23(4)
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Carducci B, Lowe RA and Dalsey W. Penetrating neck trauma: consensus and controversies. Ann Emerg Med 1986; 15: 208–215.
2. Blattman SB, Landis GS, Knight M, Panetta TF, Sclafani SJ and Burack JH. Combined endovascular and open repair of a penetrating innominate artery and tracheal injury. Ann Thorac Surg 2002; 74: 237–239. 3. Bell RB, Osborn T, Dierks EJ, Potter BE and Long WB. Management of penetrating neck injuries: a new paradigm for civilian trauma. J Oral Maxillofac Surg 2007; 65: 691–705. 4. Wu YH, Lai CH, Luo CY and Tseng YL. Tracheoinnominate artery fistula caused by migration of a Kirschner wire. Eur J Cardiothorac Surg 2009; 36: 214–216.
Downloaded from aan.sagepub.com at Mount Royal University on June 7, 2015
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