Eur J Cardiothorac Surg 2007;31:747-749. doi:10.1016/j.ejcts.2006.12.028
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Preventive ligation of the innominate artery in patients with neuromuscular disorders
Francesca Iodicea,*,
Gianluca Brancacciob,
Aldo Lauria,
Roberto Di Donatob
a Division of Anesthesia and Intensive Care, Ospedale Bambino Gesù-Palidoro, Rome, Italy
b Division of Cardiothoracic Surgery, Ospedale Bambino Gesù, Rome, Italy
Received 4 September 2006;
received in revised form 27 November 2006;
accepted 4 December 2006.
* Corresponding author. Address: Ospedale Pediatrico Bambino Gesù-Palidoro, Via Torre di Palidoro-Fiumicino 00050, Rome, Italy. Tel.: +39 06 689591; fax: +39 06 68593246. (Email: francesca_iodice{at}yahoo.it).
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Abstract
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Tracheostomy, long-term mechanical ventilation, spinal deformaties are factors that contribute in patients with neuromuscular disorders to the development of an erosion of the tracheal wall and subsequent formation of a tracheo-innominate artery fistula. This condition is fatal unless promptly treated by exclusion of the innominate artery, which is often performed under desperate circumstances. We electively adopted a preventive ligation of the innominate artery in patients at risk for trachea-innominate artery fistula (TIF). We present seven patients with neuromuscular disorders who underwent preventive ligation of the innominate artery. All seven patients survived.
Key Words: Neuromuscular diseases • Tracheo-innominate fistula • Haemorrhage
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1. Introduction
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Patients with neuromuscular disorders often require tracheotomy and long-term mechanical ventilation. This condition predisposes to tracheal wall erosion and subsequent formation of a trachea-innominate artery fistula (TIF) [1–2]. The real incidence of TIF appears to be variable ranging from 0.2 to 4.5% [3–4]. TIF bleeding occurs in <1% of patients with long-standing tracheotomies and leads to massive life-threatening haemorrhage which may totally obstruct the airway [5]. Patients with neuromuscular disorders and those affected by Duchenne muscular dystrophy (DMD) are considered at increased risk of developing tracheal erosions and haemorrhages [6]. This condition is inevitably fatal unless promptly treated by exclusion of the innominate artery, which is often performed under emergency circumstances [7].
Rather than considering only extreme surgical rescue therapy when needed, we electively adopted preventive ligation of the innominate artery in patients at risk for TIF. In our experience, this strategy has proven to be both safe and effective.
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2. Materials and methods
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We present seven patients with neuromuscular disorders who underwent preventive ligation of the innominate artery. Six were affected by DMD and one by amyotrophic lateral sclerosis. Their age and weight ranged between 20–30 years (mean age 25 years) and 25–40 kg (mean weight 30 kg), respectively. All were tracheotomized and received long-term mechanical ventilation through traditional, precurved tracheotomy tubes. Marked scoliosis and severe chest deformities were constant features.
Patients were selected on the basis of their respiratory conditions, general clinical status and risk of developing TIF. Premonitory evidence of impending TIF formation mostly relied on CT scan assessment of the structural relationship between the trachea and the innominate artery (Fig. 1
). Epiaortic Doppler and angio-MRI were utilized to evaluate the presence of an adequate collateral circulation after ligation of the innominate artery and of an intact circle of Willis.
All patients received intravenous anaesthesia utilizing propofol (5–6 mg/kg/h) or midazolam (0.1 mg/kg/h) and bolus fentanyl 1 
/kg. All vital signs were monitored continuously.
Surgery was carried out through a full (five cases) or a partial (i.e. limited to the upper-third, two cases) median sternotomy. Tracheal stoma was carefully isolated from the operating field. Thymus remnants were removed or spread out, gaining access to the innominate vein and to the underlying origin of the innominate artery, without opening the pericardium. Thereafter, careful dissection of the entire innominate artery and its main branches led to proximal and distal control of the vessel. After temporary clamping of the innominate artery, intraoperative awakening of the patients was attained. Patients were asked to respond to simple commands with simple actions, e.g. nodding or opening the eyes. This manoeuvre was used to evaluate the integrity of the cerebral circulation and early detection of potential neurological complications. Exclusion of the innominate artery was accomplished by ligation of its takeoff from the aortic arch and of the origins of the right common carotid and subclavian arteries. All patients were transferred to the intensive care unit for postoperative monitoring.
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3. Results
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All patients survived the operation and awakened immediately after surgery without neurological sequelae. Depending on collateral problems, none associated with the surgery, all patients were discharged home ±10 days after surgery. There were no late complications (follow-up 12–18 months) and none of the patients have manifested signs of tracheal haemorrhages.
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4. Discussion
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Several factors contribute to the formation of TIF, including tracheotomies below the 3rd–4th tracheal rings, over inflated cuffs and positive pressure mechanical ventilation. Anomalies of the neck vessels and spinal deformations sometimes place the innominate artery over the mid-trachea, increasing the risk of erosion by the extremities of the tracheal tubes.
We previously demonstrated how the use of flexible, tracheotomy tubes (Bivona Hyperflex) which easily adapt to the tracheal lumen, decreases the incidence of tracheal haemorrhages. When flexible tubes are used, the pressure on the tube extremity becomes parallel to the tracheal lumen, reducing the probability of tracheal bleeding [8]. However, the use of flexible tracheotomy tubes is not possible in all patients; many DMD patients have an extremely reduced pulmonary compliance and are prone to the development of pulmonary infections. In fact, providing adequate ventilation in these patients is often challenging. Flexible tracheotomy tubes do not have low-pressure cuffs which safely protect the airway during high-pressure mechanical ventilation. In these cases, we were forced to use traditional nonflexible low-pressure cuffed tracheotomy tubes (RUSCH). In this small group of patients, considered at high risk of developing TIF, we decided to perform a preventive ligation of the innominate artery, both proximally and distally. It is safer to ligate a vessel at the origin of its two main branches, rather than dissecting a vessel that is in close contact with the trachea. We used a sort of ‘no touch’ technique. In our experience, this procedure has proven safe and reliable. Most believe that ligation of the innominate artery is the treatment of choice in the acute occurrence of a TIF [9]. In our experience, the treatment of TIF under emergency conditions was never really successful, only one of our patients survived the emergency procedure. We propose to perform this operation as ‘prophylaxis’ of a TIF. Gelman and co-workers [10] noted that the risk of neurological sequelae is low, with only two cases of transient arm weakness reported out of 71 patients. Despite, some suggest to preserve the right carotid–right subclavian artery junction we had no problems with postoperative perfusion of the right arm and none of our patients revealed signs of carotid or subclavian insufficiency.
All patients received prophylactic preoperative and postoperative doses (at least 10 days) of a cephalosporin and amikacin. None of the patients showed signs of mediastinitis.
The follow-up period was short, however, we believe that this procedure is associated with a low mortality and complication rate; yet, it prevents a devastating death such as that which nearly always follows emergency TIF treatment. We present a small group of patients, and our selection criteria were limited and based exclusively on clinical status and radiological imaging.
In conclusion, we present seven patients who underwent uncomplicated preventive ligation of the innominate artery, before potential TIF formation. We do not propose ligation of the innominate artery as a routine procedure, yet, in patients at high risk of developing TIF and in those in whom flexible tracheotomy tubes cannot be utilized it may be considered a valid option.
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References
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Abstract
1. Introduction
