Commentary in reply to manuscript number: JOCS-2022-CREP-446.R1
Commentary: Too Big to Fail? – An Aggressive Strategy For a Dire
Problem
Jennifer L. Perri, M.D., M.B.A.1, Ryan P. Plichta,
M.D.1
1. Division of Cardiovascular and Thoracic Surgery, Duke University
Medical Center, Durham, NC.
Corresponding Author:
Ryan P. Plichta, M.D.
Division of Cardiovascular and Thoracic Surgery
Duke University Medical Center, Box 3864
Durham, NC 27710
Email: Ryan.Plichta@Duke.edu
Disclosures: None
Abstract:
Tracheo-innominate fistula (TIF) is a reported complication of
tracheostomy that typically presents with a herald bleed. The phenomenon
of an aorto-tracheal fistula has similar pathology and presentation to
TIF, but no standard surgical repair. In the manuscript by Musgrove et
al. in the Journal of Cardiac Surgery the authors propose a
surgical treatment, that is reproduceable for the correct anatomic
configuration - an ascending and aortic arch replacement, pericardial
patch of the tracheal defect, and omental flap coverage to prevent
infection. While this intervention seems a large undertaking for a small
defect, it is a safe and durable repair.
A known complication of tracheostomy is a tracheo-innominate fistula
(TIF). The incidence of this complication is estimated as 0.1-1%, with
the most common presenting symptom being hemorrhage.1A less frequently described, but similar anatomic entity, is the
aorto-tracheal fistula. These are also rare, and can occur after
radiation or prior aortic replacement. This almost uniformly fatal
pathology has a similar presentation to TIF, although the options for
repair are not well described.
Musgrove et al. report a unique case in which a 48-year-old patient
presents with small volume hemoptysis in the setting of prior
radiation.2 Bronchoscopy revealed a small defect in
the trachea near the carina. They describe a technique whereby a patient
undergoes a zone 1 arch replacement for the infected aorta and a
combination pericardial patch and omental flap to cover the tracheal
defect. While the patient in this example did suffer one complication,
twisting of the omental flap resulting in gastric outlet obstruction,
the concept of the repair is clear and reproducible. It seems that the
procedure could be readily utilized in the appropriate patient. The
authors perform an ascending and arch replacement with innominate artery
debranching using hypothermic circulatory arrest, antegrade cerebral
perfusion, and both antegrade and retrograde
cardioplegia.2
Three concerns arise in this type of case, touched on by the authors.
First, the defect in the aorta. In this report the tracheal defect is
described as 3 mm. Fortunately the patient had a small defect and was
able to present in stable condition for further work-up of hemoptysis.
Larger, more hemodynamically significant defects likely result in poor
early survival. Mortality from a tracheo-arterial fistula based on case
reports in the literature (that is, aorta or innominate fistula) is
approximately 75%.3 There is no mention of
endovascular temporization, but one could imagine a role this may play
when the anatomy allows for it. Second, a major concern of the operation
is the infected field and suitable choice of aortic and arch
replacement. The authors note they could have used a homograft. Rifampin
soaked Dacron is another option. The addition of the omental flap likely
played a large role in the success of the case. Third, the location of
the fistula with respect to the great vessels; in this scenario the
authors use a multibranch device and only needed to debranch the
innominate artery. However, when faced with a larger defect, or where
infected aortic tissue spans the takeoff of the great vessels, a total
arch replacement may be necessary. In the particular presentation
described by Musgrove et al2, their technique of
repair is both large in size and scope but also appropriate for the
given pathology.
While the significance of this nearly uniformly fatal pathology cannot
be minimized, this is a particularly large operation to address the
repair of a small hole. The location of the fistula in the posterior
arch makes a less invasive operation challenging, especially in an
irradiated field with active infection. Similarly, operating in a redo
chest with a previously placed aortic graft would pose a problem when
attempting to isolate the fistula without the adjunct of cardiopulmonary
bypass or circulatory arrest. A side biting clamp and patch repair of
the hole might be sufficient, but may not result in a durable repair.
Endovascular stent grafting has been used for treatment of
TIF4, however when applied to a fistula to the aortic
arch, infection of the stent graft poses a prohibitive risk. Moreover,
seal is not possible at the takeoff of the great vessels.
A key lesson in this paper is that rather than trying to patch or
inadequately treat the 3 mm tracheal defect, the authors successfully
used a safe method to resect all infected tissue and replace the aorta
with a graft that is protected from infection by an omental patch. We
(Figure 1) commend the authors for performing a well planned and
executed repair of an aorto-tracheal fistula. Not only did the patient
survive beyond one year, but suffered no infectious complications. The
authors have provided a valuable tool for treatment of a rare, deadly,
and daunting complication efficiently, effectively, and in a
straightforward manner.
References:
- Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate artery
fistula after percutaneous tracheostomy: three case reports and a
clinical review. Br J Anaesth. 2006 Jan;96(1):127-31. doi:
10.1093/bja/aei282.
- Kelsey A. Musgrove, Daniel McCarthy, Andreas de Biasi. Aortic Arch
Replacement and Autologous Pericardial Tracheal Patch for an
Aorto-Tracheal Fistula. J. Card. Surg. March 18, 2022.
doi: 10.22541/au.164762563.39269825/v1
- Brigitte Reger, Reiner Neu, Hans-Stefan Hofmann, Michael Ried, High
mortality in patients with tracheoarterial fistulas: clinical
experience and treatment recommendations. Interactive
CardioVascular and Thoracic Surgery. 2018 Jan;26(1):12-17.
10.1093/icvts/ivx249
- Taechariyakul T, Keller F, Jahangiri
Y: Endovascular
treatment of tracheoinnominate artery fistula: case report and
literature review with pooled cohort analysis. Semin Thorac
Cardiovasc Surg. 2019,
32:77-84. 10.1053/j.semtcvs.2019.08.006
Figure 1: Jennifer L. Perri, MD/MBA (left) and Ryan P. Plichta MD
(right)