Prevention of a Tracheal Arterial Fistula

Prevention of hemorrhage after a tracheostomy is accomplished by

1) correct placement of the tracheostomy at the level of the second or third cartilaginous rings;

2) avoidance of sharply angled (90°) and excessively rigid tracheostomy tubes;

3) checking the alignment of the tube in the trachea with a flexible bronchoscope at the completion of tracheostomy. It is always advisable to have a variety of tracheostomy tubes available;

4) avoiding overinflation of tracheal cuffs. Check intracuff pressures routinely.

For prevention of hemorrhage after tracheal resection and reconstruction

1) do not dissect out the brachiocephalic artery unless necessary (adherence to trachea, prior surgery or dissection for tumor);

2) interpose robust, vascularized tissue between the dissected artery and tracheal anastomosis (sternohyoid muscle, thymus, omentum);

3) suture the sternohyoid muscle to the trachea over an artery if tracheostomy is anticipated, possibly later postoperatively;

4) do not use prosthetic materials, especially in contact with major vessels.

For a description of prevention of a tracheal-arterial fistula in cervicomediastinal exenteration, see Chapter 34, "Cervicomediastinal Exenteration and Mediastinal Tracheostomy."

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