Carotid Artery Laceration and Secondary Pseudoaneurysm of the Innominate Artery: Previously Unreported Life-Threatening Complications of Percutaneous Dilatational Tracheostomy

Abstract

SESSION TYPE: Critical Care Student/Resident Case Report Posters IPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Percutaneous dilatational tracheostomy (PDT) has become an appropriate alternative to conventional surgical tracheostomy and has gained worldwide acceptance. It is now performed by a diverse array of physician specialists. Complications are relatively uncommon.CASE PRESENTATION: A 57-year-old male patient with multiple comorbidities required prolonged mechanical ventilatory support due to hypoxic respiratory failure. For this reason, tracheostomy was deemed necessary. PDT was initiated with a small midline transverse incision between the second and third tracheal rings. The introducer needle was inserted into the trachea under direct visualization via a fiberoptic bronchoscope. Two successive dilators were then passed into the trachea. The patient began to bleed profusely as a number 8 tracheostomy tube was being placed over the dilator. Exploration of the patent’s neck allowed for identification of a lacerated right common carotid artery. Bleeding was controlled by vertical mattress sutures. The patient required transfusions of six units of packed red blood cells. After stabilizing the patient in the operating room, the patient was transferred to the intensive care unit. Angiography of the great vessels of the neck was subsequently performed due to hypotension to determine whether the patient was actively hemorrhaging. No bleeding was identified but an innominate artery pseudoaneurysm was discovered. Patient underwent successful repair of the pseudoaneurysm as well as conventional tracheostomy.DISCUSSION: There are several known complications associated with PDT, typically divided into early (within one week) and late (greater than one week). Previously described early complications include local bleeding (often associated with vascular anomalies), mucus plugging, tracheitis, and accidental de-cannulation. To our knowledge, neither carotid artery laceration nor innominate artery pseudoaneurysm formation has been previously reported as a complication of PDT. A recent multi-institutional analysis of tracheostomy complications demonstrated a significantly higher rate of early postoperative bleeding with PDT (6.6%) when compared to conventional tracheostomy (1.9 %). The authors also determined that the use of outer flange tracheostomy tube sutures reduce this complication. It has also been suggested that hemorrhage due to variant vascular anatomy may be minimized by pre-procedural ultrasound. A preoperative ultrasound of the vascular structures of our patient’s neck was not performed, but it seems unlikely that this investigation would have prevented the laceration of his carotid artery or the secondary innominate artery pseudoaneurysm formation.CONCLUSIONS: As PDT becomes more commonplace, we hope that our report effectively illustrates that serious complications can arise from this relatively non-invasive procedure.1) A multi-institutional analysis of tracheotomy complications. The Laryngoscope , 122: 38-45. doi: 10.1002/lary.22364DISCLOSURE: The following authors have nothing to disclose: Parag Brahmbhatt, Ryland Byrd, Thomas RoyNo Product/Research Disclosure InformationDepartment of Internal Medicine, East Tennessee State University, Johnson City, TN