Long-term tracheostomy may cause a fistula’s development between the trachea and the brachiocephalic trunk due to tracheitis, focal necrosis, cartilage loss, and then fistulization (Komatsu et al. 2013). Common risk factors are low tracheostomy position, excessive cuff inflation, and steroids (Qureshi 2018). The rapid management and the early control of the hemorrhage play a crucial role in patient survival (Komatsu et al. 2013; Seung et al. 2012). The primary goal is to secure the airway by hyperinflating the tracheal cuff and an endotracheal tube’s advancement.
Clinical signs of incipient TIF are small amounts of blood from the tracheostomy, hemoptysis, or pulsatile movements of the tracheal cannula (Schaefer and Irwin 1995). It can be challenging to confirm the diagnosis of TIF with computed tomography angiography and may require bronchoscopy and catheter angiography to determine the location of the bleeding (Seung et al. 2012). In a typical emergency, it is not feasible to establish a sophisticated work-up. A rapid diagnosis will allow the decision-making for an emergent therapy concept (Reger et al. 2018).
There are various techniques available for the treatment of acute TIF. The immediate surgical treatment is the most common approach to controlling bleeding and reconstructing the vessel and the tracheal defect (Komatsu et al. 2013). A median sternotomy is required to gain access. Once the TIF is identified, the vascular clamps are placed to stop the bleeding. The defect can be reconstructed by ligation or resection with replacement by a vascular prosthesis. Reconstruction with a bypass is also possible in emergencies. The mortality rate after emergency surgery has been reported to be beyond 50%. Neurological deficits of 10% and sternal wound complications of 39% were reported (Seung et al. 2012; Reger et al. 2018; Nakai et al. 2013).
Endovascular therapy is increasingly considered an attractive and practical approach to treat arterial bleeding due to fistulas and vascular erosions. There are few publications in the English literature discussing the endovascular treatment of TIF, either as a stand-alone treatment or as a bridging concept for patients in a poor clinical condition to operate on them in the subacute phase after at least partial recovery (Taechariyakul et al. 2020).
Taechariyakul et al. (2020) identified 261 published cases of TIF in a meta-analysis and reported a lower procedure-related complication rate (30% vs. 50%, p = 0.045) and 30-day mortality (9% vs. 23%, p = 0.008) for the endovascular treatment compared to surgery. Endovascular stent-graft implantation is a rapid and safe procedure. However, possible complications such as graft infection, graft occlusion, and postoperative rebleeding due to tracheal erosion must be considered (Nakai et al. 2013).
In our case, we opted for an endovascular therapy due to the high-risk of the already unstable patient and because open surgery was considered hazardous, especially with a vaguely identified bleeding source. In the English literature, reports of post-procedural complications such as occlusion of the right carotid artery or right subclavian artery leading to steal syndrome can be found. Therefore, the decision for the correct stent dimensions and position is crucial.