Brachiocephalic artery hemorrhage is a life-threatening complication with high mortality [
A 32-year-old female was admitted because of intracerebral bleeding due to a high-flow arteriovenous malformation of the posterior inferior cerebellar artery. It was treated by neuroradiological intervention and neurosurgical extirpation. Because of prolonged ventilation, translaryngeal tracheostomy using the Fantoni technique was performed. Excessive oropharyngeal hemorrhage occurred six days later, during a routine bedding procedure. The otorhinolaryngologist could not identify the source of bleeding and placed a nasopharyngeal, oropharyngeal and hypopharyngeal tamponade. Blood loss was reduced, and it stopped completely after about 15 minutes. Angiographic computer tomography could not show the source of bleeding. Two hours later, a second massive hemorrhage occurred from the oropharynx beside the tamponade and tracheal tube. The tube was overblocked extensively. A second attempt to identify the source of bleeding by angiography failed. The patient was transported to the operating room for revision of tracheostomy. An erosive lesion in the dorsal wall of the brachiocephalic artery was found (Figure
Intraoperative view (Case
A 19-year-old male, who had suffered severe head and thorax trauma several months ago, was presented to an otorhinolaryngologist. A Griggs PDT was performed two months ago. Around the tracheostoma was a thick scab of old blood. For a diagnostic tracheoscopy, the otorhinolaryngologist removed the tracheal speech cannula. Sudden excessive bleeding occurred from the nose and mouth. A cuffed tracheal cannula was inserted and overinflated immediately to prevent the aspiration of blood by the suspected nasopharyngeal bleeding. A tamponade of the oropharynx, nasopharynx and hypopharynx was given, and volume resuscitation was started. After transportation to the university hospital, a second severe hemorrhage occurred. Angiography showed no source of bleeding. After slight tracheal cuff deflation an escape of the contrast agent was observed from the proximal brachiocephalic artery (Figure
Angiographic scan (Case
Brachiocephalic artery hemorrhage is a life-threatening complication after tracheostomy. Warning symptoms, such as aspiration of blood, bleeding beside the tracheal cannula, or pulsation of the cannula, can be absent. The first signs of bleeding can be misleading and occur as a naso-oropharyngeal hemorrhage, especially in cases where the contact between the tissue and the cannula is tight. Fiberoptic bronchoscopy and angiography have been performed with mixed results [
As massive hemorrhage begins, immediate arterial compression by overinflation of the cuff, control of the airway, and subsequent surgical treatment of the injured artery were lifesaving.
In the first case, the translaryngeal tracheostomy produced a tracheal ring fracture. By extraction of the cone cannula during the PDT using the retrograde Fantoni technique [
Ultrasound examination detects the anatomical relation of major vessels to the trachea [
TIF formation was reported after long-term pressure due to a “Tracheosafe” device [
TIF is a likely cause of massive hemorrhage in patients after tracheostomy. Overinflation of the cuff was lifesaving in both cases. Ultrasound examination was established at our ICU to detect anatomical variations before PDT.
Due to the life-threatening nature of the hemorrhage, fiberoptic tracheoscopy is required regularly in patients after tracheostomy for early detection of endotracheal injuries, such as tracheal ulceration and pressure necrosis.