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LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 3  |  Page : 448-449

A rare case of an aberrant innominate vein causing posttracheostomy haemorrhage


1 Department of Neurosurgery, Bangalore Medical College and Research Institute and PMSSY Super Speciality Hospital, Bengaluru, Karnataka, India
2 Department of CTVS, Bangalore Medical College and Research Institute and PMSSY Super Speciality Hospital, Bengaluru, Karnataka, India

Date of Web Publication5-Jun-2015

Correspondence Address:
Vikas Naik
Department of Neurosurgery, Bangalore Medical College and Research Institute and PMSSY Super Speciality Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.158265

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How to cite this article:
Naik V, Patil BB, Abhilash V, Bhaganagare A, Pai S B, Patil M D. A rare case of an aberrant innominate vein causing posttracheostomy haemorrhage. Neurol India 2015;63:448-9

How to cite this URL:
Naik V, Patil BB, Abhilash V, Bhaganagare A, Pai S B, Patil M D. A rare case of an aberrant innominate vein causing posttracheostomy haemorrhage. Neurol India [serial online] 2015 [cited 2019 Sep 19];63:448-9. Available from: http://www.neurologyindia.com/text.asp?2015/63/3/448/158265


Sir,

Tracheostomy is one of the routinely performed surgeries by neurosurgeons in severely morbid patients who require a long term ventilation after major surgery, in patients who are unable to maintain their airway and also in patients suffering from severe head injury. [1],[2],[3],[4],[5] A post-tracheostomy tracheo- arterial fistula is a very rare complication. [1] A tracheo-venous fistula is even rarer. [1] The authors report a case of a rare trachea- venous fistula due to an aberrantly situated high innominate vein.

A 32-year old female patient was operated for a large falcotentorial meningioma. She underwent tracheostomy on postoperative day 5 and her neurological recovery was uneventful. As she had difficulty in swallowing, the tracheostomy tube was left in-situ for a week. As her swallowing improved and her tracheobronchial secretions decreased, it was decided to remove her tracheotomy tube. Immediately following the deflation and removal of the tracheostomy tube, there was a massive bleed of about 1- 1.5 litres from the tracheostomy site. The tracheostomy tube was reinserted and its cuff inflated. Her resultant hypovolemic shock was overcome by transfusing blood and other blood products. However, despite all possible measures, a small amount of blood kept oozing from the tracheostomy site. After 4 hours, she once again had hemorrhage of around 500ml from the tracheostomy site, became hypotensive and was not responding to resuscitative measures. With the help of cardiovascular colleagues, a transmanubrial trajectory for an anterior thoracic approach was sought. The tracheostomy incision was extended in a linear fashion upto mid sternum. The manubrium sterni, was partially resected, the sterno-clavicular joint was disarticulated and the medial half of right clavicle was removed. A tracheo- venous fistula due to a rent in a high riding innominate vein at the thoracic (T) 3-4 level in close vicinity of the cuff was found [Figure 1]. The rent in the vein was repaired using sutures and liga- clips [Figure 2]. A larger sized tracheostomy tube was inserted. The patient gradually recovered but developed posterior watershed infarct in the right middle cerebral artery territory. She unfortunately died of septicaemia 3 weeks after this event.
Figure 1: Pictorial representation of a high riding innominate vein

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Figure 2: X-ray chest showing the liga clips (arrow)

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Although tracheostomy is a simple procedure, many complications such as bleeding, infection, aspiration, false passage, tube blockage, surgical emphysema, tracheal stenosis and rarely tracheo- arterial fistula have been reported. [1],[2],[3],[4],[5] The brachiocephalic artery is most commonly involved in the fistulous communication followed by the carotid artery, brachiocephalic/innominate vein and aortic arch. [4] The incidence of tracheo-vessel fistula is 0.6-0.79%. It usually occurs due to performance of a low tracheostomy below the fourth tracheal ring or if there is a high riding vessel. [1],[4] Various mechanisms have been proposed for the development of the fistula including a persistent cuff pressure causing tracheal necrosis along with the vessel exerting pressure on the same site due to its pulsations, the tip of tube rubbing against the tracheal wall, a piston like movement of the tracheostomy tube connected to the ventilator, local infection, neoplastic invasion or necrosis of the cartilage. [1],[2],[4],[5] The method of prevention of this fistula is to not perform the tracheostomy below the third tracheal ring, achieving a periodic deflation of the cuff, avoidance of infection, and prevention of abnormal movement of the tracheostomy tube that is likely to erode the vessel wall. In the presence of active bleeding at that site, an overinflation of the tube to prevent aspiration and to control bleeding is advocated. The definitive management of this entity is to identify the bleeding point and perform an open repair of the vessel wall in case conservative measures are insufficient to stop the bleeding.

 
  References Top

1.
Praveen CV, Martin A. A rare case of fatal haemorrhage after tracheostomy. Ann R Coll Surg Engl. 2007;89:w6-w8.  Back to cited text no. 1
    
2.
Biller HF, Ebert PA. Innonimate artery haemorhhage complicating tracheostomy. Ann Otol Rhinol Laryngol. 1970;79:301.  Back to cited text no. 2
    
3.
Fujimoto K, Abe T, Kumabe T, Hayabuchin N, Nozaki Y. Anomalous left brachiocephalic (Innominate) vein: MR demonstration. AJR Am J Roentgenol. 1992;159:479-480.  Back to cited text no. 3
    
4.
Virendra Budhiraja, Rakhi Rastogi. Unusual origin and potentially hazardous course of major blood vessels in neck-A clinically relevant rare case. Int J Anat Var 2010;3:61-62.  Back to cited text no. 4
    
5.
Upadhyaya PK, Bertellotti R, Laeeq A, Sujimoto J. Beware of aberrant innominate artery. Ann Thoracic Surg. 2008;85:853-854.  Back to cited text no. 5
    


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