CG Ball

DF Toit du

E Firoozmand

JL Sperry

L Pedrini

S Ozlugedik

T Oda

XL Wang

Y Bito

Yohei Okada

Hiromichi Narumiya

Wataru Ishii

Iiduka Ryoji

Crossref

CASE REPORT Open AccessDamage control management ofinnominate artery injury with tracheostomyYohei Okada*, Hiromichi Narumiya, Wataru Ishii and Iiduka RyojiAbstractInnominate artery injury is a rare, but catastrophic complication of tracheostomy. We present a case of severehemorrhagic shock in a 79-year-old male with innominate artery injury that occurred during tracheostomy.Despite temporary innominate artery isolation, the regional forehead saturation was 60 % without laterality.Because adequate cerebral blood flow was apparently maintained through collateral flow, we ligated theinnominate, right carotid, and subclavian arteries. We confirmed adequate blood flow to the brain and theright subclavian artery through collateral circulation after ligation using computed tomographic angiography.A damage control management, which involves ligating the injured innominate artery to arrest hemorrhageand monitoring regional forehead saturation for brain ischemia, can be a considerable procedure for thetreatment of severe hemorrhagic shock due to innominate artery injury.Keywords: Damage control surgery, rSO2, Near-infrared spectroscopy, Tracheo-innominate fistula, InnominatearteryBackgroundInnominate artery (IA) injury, including formation of atracheo-innominate fistula, is a rare but severe compli-cation of tracheostomy that is associated with high mor-tality due to the resultant severe hemorrhagic shock [1].A damage control strategy consisting of prompt controlof bleeding and management to maintain physiologicalhomeostasis—crucial to avoiding the deadly triad ofhypothermia, acidosis, and coagulopathy—is essential ina patient with severe hemorrhagic shock, such as follow-ing a neck vessel injury [2]. Moreover, generally, theneck vessel surgery has the risk of severe neurologicalcomplications, so that we should avoid brain ischemia aspossible in such a case.Case presentationA 79-year-old male, with terminal lung cancer at theright upper lobe, had been in another hospital andintubated for 3 weeks since an accidental airway ob-struction. His doctor performed the tracheostomy ina surgical manner at the bedside. During the proced-ure, continuous arterial bleeding at the surgical siteoccurred. The doctor could not detect the bleedingartery clearly, but direct manual compression with anindex finger at the surgical site provided temporaryhemostasis. On arrival at our emergency department,he was intubated and in severe hemorrhagic shockdespite having received transfusion of six units ofpacked red blood cells concentration (PRBC) and sixunits of fresh frozen plasma (FFP).Arterial blood gas assessment revealed metabolic and re-spiratory acidosis and anemia [pH 7.09, pCO2 71 mmHg,pO2 193 mmHg, HCO3− 21.0 mmol/L, base excess(BE) −8.3 mmol/L, lactate (Lac) 5.5 mmol/L, hemoglobin(Hb) 7.9 g/dL, hematocrit (Ht) 22 %, FiO2 1.0], and bloodtests showed coagulopathy [PT 35.3 %, PT-INR 1.68, acti-vated partial thromboplastin time (APTT) 56.2 s, fibrinogen(Fib) 84 mg/dL]. These data showed that his condition wasin severe hemorrhagic shock and coagulopathy.The patient was taken up for emergency surgery inview of the serious nature of the injury.During surgery, because of the clinical impression ofan injury to the distal IA or proximal common carotidartery, a right supraclavicular incision was made,followed by dissection of the platysma, division of theright sternocleidomastoid muscle, and resection of the* Correspondence: okadayohei1127@yahoo.co.jpDepartment of Emergency and Critical Care Medicine, Japanese Red CrossKyoto Daini Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan© 2016 Okada et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made.Okada et al. Surgical Case Reports  (2016) 2:17 DOI 10.1186/s40792-016-0144-7right clavicular head. The exposure revealed that bothinnominate and right common carotid arteries were in-jured (Fig. 1). After innominate, the right subclavian andright common arteries were isolated and primary repairand graft interposition of the arteries was attempted, butproved too difficult because of atherosclerosis. After anhour into the surgery, the patient showed worseninghypothermia (34 °C), metabolic acidosis, and clinical evi-dence of coagulopathy; therefore, we decided a damagecontrol strategy. Despite clamping of the IA for about10 min in attempting primary repair, the regional oxygensaturation (rSO2) of the forehead, measured by near-infrared spectroscopy (NIRS; INVOS 5100C Cerebral/Somatic Oximetry Monitors™; Covidien, USA), was ap-proximately 60 % without laterality. It seemed that ad-equate blood circulation to the brain was maintainedthrough the collateral flow; therefore, we decided to li-gate the innominate, right carotid, and subclavian arter-ies. The wound was packed with gauze for temporarywound closure. Overall, the operation lasted for 1 h and25 min, with a recorded blood loss of 1190 g and trans-fusion of 16 units PRBCs and 10 units of FFP.Postoperative contrast-enhanced computed tomog-raphy revealed no apparent acute cerebral ischemia andextravasation, and the distal right common carotid andright subclavian arteries were enhanced through the cir-cle of Willis (Fig. 2). A right tracheal shift due to adhe-sions caused by lung cancer was also revealed, indicatinga course of the IA anterior to the third tracheal ring.After admission to the intensive care unit, coagulopa-thy and hypothermia were corrected with massivetransfusion (overall transfusions: PRBCs 24 units andFFP 26 units).No symptoms of hypo-perfusion of the right upperlimbs and brain were observed; therefore, an extra-anatomical bypass was deemed unnecessary. On post-operative day 1, we closed the wound definitively. Onpostoperative day 7, the patient was transferred to asub-acute, community hospital.DiscussionIA injury is a rare, but severe, complication of tracheos-tomy that is associated with high mortality due to the re-sultant severe hemorrhagic shock [1]. Such an injurymay be the result of an anatomical anomaly [3]. In thepresent case, a right tracheal shift due to adhesionscaused by lung cancer and the course of the IA anteriorto the third tracheal ring were the major causative fac-tors for the catastrophe. Endovascular management be-came the method of choice when treating a stablepatient with an IA injury, but should be avoided in ahemodynamically unstable patient, who would requireexpeditious transfer to the operating room [4].The most preferred exposure for a penetrating ZONE1 neck injury (from the bottom of the cricoid cartilageto the clavicles) is a median sternotomy combined withFig. 1 Diagram of the innominate arterial injury and the surgicalapproach. A right supraclavicular incision with resection of the rightclavicle head revealed injury to both innominate and right commoncarotid arteries. IA innominate artery, SCA subclavian artery, CCAcommon carotid arteryFig. 2 CT angiography of neck vessels. (Arrow) Ligation of innominateartery. The distal right common carotid and right subclavian arterieswere enhanced by collateral flow through the left common carotidartery and the circle of WillisOkada et al. Surgical Case Reports  (2016) 2:17 Page 2 of 4an anterior neck or supraclavicular incision. Another ap-proach involves a supraclavicular incision with or with-out resection of the head of the clavicle [5]. However, inthis case, we selected a supraclavicular incision with cla-vicular head resection to obtain adequate exposure,while also preparing for a median sternotomy, becausewe thought median sternotomy had hemorrhagic risk inview of possible adhesions due to lung cancer.Surgical procedures are divided into two strategies:one is a ‘definitive repair’ including primary repair asdirect suture, graft interposition, and a bypass graft fromthe ascending aorta, and the other is a ‘damage controlstrategy’. The concept of a damage control strategy hasimmediate control of bleeding and temporary woundclosure, as its objective minimized operative time andintervention for at a moment of physiological frailty, andplaned re-surgery [6]. In general, direct suture and graftinterposition with vein patch or pericardium are the firstchoice of treatment [5] but were too difficult to carryout in the present case because of the patient’s athero-sclerosis. Bypass grafting from the ascending aorta hasbeen reported as a radical treatment in some cases [7].However, this patient showed physiological frailty, whichwas worsening hypothermia (34 °C), metabolic acidosis,and clinical evidence of coagulopathy also known as the‘deadly triad’; therefore, we had to choose a balloon tam-ponade, temporary shunt, or ligation as the damage con-trol method [8]. A balloon tamponade is one ofconsiderable damage control methods, but we could notprepare it at the moment. A temporary shunt is a damagecontrol method for a vascular injury and is more commonlyassociated with limb fracture. It involves the insertion of aplastic tube into the injured vessel that is then tightly se-cured in place with a silk tie to ensure that the tube will notbe dislodged [8]. Complications of this procedure includere-bleeding and thrombus embolization. In the presentcase, we were wary of generating an embolism to the brain;therefore, we tend to avoid these methods. However, if theinjury were to the subclavian artery or another vessel, ex-cepting the common carotid artery, we would have usedthis procedure as a damage control method. Ligation is theeasiest and fastest method to control bleeding but is associ-ated with the risk of ischemia and neurologic deficit. Insome previous articles reporting on innominate artery in-jury caused by a trachea-innominate fistula, ligation of theinnominate artery could be considered as the first choice tocontrol massive hemorrhage and was associated with a highsurvival rate with regard to re-bleeding and infection [9].Previous articles have reported that such flow interruptionwould not yield significant neurologic or vascular complica-tions because of the collateral flow through the left com-mon carotid artery and the circle of Willis [9].Monitoring rSO2 by near-infrared spectroscopy (NIRS)is an invasive method for detecting brain ischemia incircumstances such as carotid surgery [10]. In a previousarticle [11], it was reported to be useful in deciding thesurgical management of bleeding from a bracheo-innominate fistula. In the present case, after isolation ofthe innominate artery, the patient’s rSO2 values seemedadequate to obtain adequate blood flow to the brainwithout laterality; therefore, we decided to proceed withthe ligation of the innominate artery immediately. Onmonitoring after ligation, we noted that the value hadnot changed. Monitoring the rSO2 is considered as auseful method to determine selection of the surgical pro-cedure. In our case, we confirmed adequate blood flowto the brain and the right subclavian artery through col-lateral circulation after ligation using computed tomo-graphic angiography. In a damage control strategy,planed re-surgery is usually performed. However, thiscase showed no symptoms of hypo-perfusion of the rightupper limbs and brain after ligation; therefore, we didnot perform planed re-surgery as an extra-anatomicalbypass.ConclusionsAs a damage control strategy, ligation of the IA togetherwith monitoring of the rSO2 of the forehead for evaluat-ing brain ischemia can be considered a preferable pro-cedure for the treatment of severe hemorrhagic shockdue to IA injury.ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompanyingimages. A copy of the written consent is available for re-view by the editor of this journal.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsYO, WI, and RI were the major decision-makers during the surgery. HN wasrevising the manuscript and study supervision. All authors have read andapproved the final manuscript.AcknowledgementsThe authors are grateful for the helpful support from Dr Satoshi Higaki, DrKen Sakakibara, Dr Yusuke Arai, Dr Tetsuya Ichikawa, Dr Sakiko Hiraki, DrYusuke Ohiwa, Dr Michitaro Miyaguni, and Dr Kenji Kandori.Received: 24 November 2015 Accepted: 12 February 2016References1. Maruti Pol M, Gupta A, Kumar S, Mishra B. Innominate artery injury: acatastrophic complication of tracheostomy, operative procedure revisited.BMJ Case Reports; 2014. doi:10.1136/bcr-2013-201628.2. Firoozmand E, Velmahos GC. Extending damage-control principles to theneck. J Trauma. 2000;48:541–3.3. Ozlugedik S, Ozcan M, Unal A, Yalcin F, Tezer MS. Surgical importance ofhighly located innominate artery in neck surgery. Am J Otolaryngol.2005;26:330–2.Okada et al. Surgical Case Reports  (2016) 2:17 Page 3 of 44. du Toit DF, Odendaal W, Lambrechts A, Warren BL. Surgical andendovascular management of penetrating innominate artery injuries.Eur J Vasc Endovasc Surg. 2008;36:56–62.5. Sperry JL, Moore EE, Coimbra R, Croce M, Davis JW, Karmy-Jones R, et al.Western Trauma Association critical decisions in trauma: penetrating necktrauma. J Trauma Acute Care Surg. 2013;75:936–40.6. Kenneth D Boffard, editors. Manual of Definitive Surgical Trauma Care. ThirdEdition. International Association for Trauma and Intensive Care. 2011.7. Bito Y, Hirai H, Sasaki Y, Hosono M, Nakahira A, Suehiro Y, et al. Successfulsurgical treatment of traumatic transection of the innominate artery: a casereport. Ann Vasc Dis. 2014;7:165–8.8. Ball CG. Damage control resuscitation: history, theory and technique. CanJ Surg. 2014;57:55–60.9. Wang XL, Xu ZG, Tang PZ, Yu Y. Tracheo-innominate artery fistula: diagnosisand surgical management. Head Neck. 2013;35:1713–8.10. Pedrini L, Magnoni F, Sensi L, Pisano E, Ballestrazzi MS, Cirelli MR, et al. Isnear-infrared spectroscopy a reliable method to evaluate clamping ischemiaduring carotid surgery? Stroke Res Treat. 2012;2012:156975.11. Oda T, Yasunaga H, Maki J, Shimauchi T, Makimoto Y, Kawakami T, et al.Effectiveness of near-infrared spectroscopy during surgical repair oftracheo-innominate artery fistula. J Artif Organs. 2011;14:245–8.Submit your manuscript to a journal and beneﬁ t from:7 Convenient online submission7 Rigorous peer review7 Immediate publication on acceptance7 Open access: articles freely available online7 High visibility within the ﬁ eld7 Retaining the copyright to your article    Submit your next manuscript at 7 springeropen.comOkada et al. Surgical Case Reports  (2016) 2:17 Page 4 of 4

Surgical Case Reports

Damage control management of innominate artery injury with tracheostomy

https://surgicalcasereports.springeropen.com/track/pdf/10.1186/s40792-016-0144-7?site=surgicalcasereports.springeropen.com

Damage control management of innominate artery injury with tracheostomy

Abstract

Similar works

Full text

Available Versions

Crossref