Tracheo-innominate artery fistula after tracheostomy.

F istula formation between the trachea and the innominate artery is a rare complication of tracheostomy (1). The survival rate in patients who develop bleeding from a tracheo-innominate artery fistula (TIF) has been reported as 14.3%, and only patients who received immediate surgical treatment survived (2). Of those patients who develop a TIF, 78% do so within the first 3 wk after tracheostomy (3). One of the proposed mechanisms of fistula formation is mucosal necrosis due to pressure caused by the elbow, tip, or cuff of the tracheostomy tube (2). Clinical presentations and treatment of TIF have been described mainly in the surgical literature (1–7). However, because anesthesiologists may be involved in treating this emergency, they must be familiar with the therapeutic steps. We present a patient who developed a TIF and died as a consequence of massive hemorrhage into the tracheobronchial tree with asphyxia. We discuss potential preventative measures that should be followed to decrease the probability of formation of a tracheo-arterial fistula, as well as important diagnostic and therapeutic steps the anesthesiologist must take in managing this severe tracheostomy complication.