figure 27-2 Emergent control of a hemorrhage. A, When the hemorrhage is from direct erosion by the side of a tracheostomy tube, the bleeding point is at the lower margin of the stoma. Digital pressure on this spot, pressing down and also forward toward the sternum, provides control. Inflation of the cuff alone is unlikely to check bleeding, although it will help to keep the distal airway free of blood. Digital pressure must be maintained into the operating room. B, Where the fistula is the result ofero-sion through the trachea by a cuff or tube, an endotracheal tube with the cuff located at the site of the fistula and hyperinflated will tamponade the hemorrhage.

omental pedicle is desirable. Control of the hemorrhage is maintained with digital pressure during the initial dissection. Proximal dissection of the brachiocephalic artery should be done with the greatest of care and patience, since there may be only a very short segment of uninvolved artery between the aortic arch and the fistula. If the left carotid artery arises from the aorta as a common trunk with the brachiocephalic artery, care must be taken to clamp and divide the brachiocephalic artery distal to the carotid origin. Distal arterial control is usually obtained just proximal to the bifurcation of the brachiocephalic artery into the right carotid and subclavian arteries. In the rare case where both carotids arise from a single trunk from the aorta, a carotid reconstruction is mandatory (see Chapter 1, "Anatomy of the Trachea"). The left brachio-cephalic vein may be divided to enlarge the exposure, if retraction is not enough. This possibility negates placement of a central venous line on the left preoperatively. Erosion into the artery is usually of sufficient size and with enough adjacent damage so that primary repair of the artery is unwise and resection is elected (Figure 27-3B). Placement of a graft in this contaminated and potentially infected field seems unwise, although it has been done successfully. A graft can be placed from low on the aortic arch, passing to the right side of the field, if restoration is essential. If this is too close to the contaminated area, then a crossing graft can be placed from the left subclavian artery, above the area of the fistula.

Neurologic sequelae due to division of the innominate artery, in contrast to division of the common carotid artery, are extremely rare.4 Elective division of the brachiocephalic artery during mediastinal exenteration under controlled circumstances has proved safe.5 Our preferred method of management is to resect the damaged artery and oversew both ends with double layers of fine vascular suture material (Figure 27-3C). Both arterial stumps are buried in substantial healthy tissue, using either thymus or strap muscle as available. Simple double ligation of the artery, even with division, is dangerous, since later erosion of these large ligatures may occur with secondary hemorrhage. If an arterial graft is used, then it is probably wise to advance an omental pedicle substernally to protect the graft.

Tracheal resection is usually unnecessary if the trachea is otherwise normal, since the erosion occurs at the stomal margin. A new stoma is made proximally at an appropriate level (second or third tracheal rings), since the patient usually still requires ventilation (see Figure 27-3C). A tube that is long enough to pass beyond the previous stoma is placed. It may be necessary to fashion a tube using an endotracheal tube with a large-volume cuffand a movable tracheostomy flange to obtain sufficient length. The margins of the old stoma are debrided conservatively and the stoma closed with pedicled or medialized strap muscle. If for any reason there is concern about placing a new tracheostomy tube, then the patient may be managed with an endotracheal tube for a time. If needed, a second tracheostomy may be established later, when the operative field is well sealed. In this case, the site for the possible later tracheostomy insertion should be marked with a single silk suture on the tracheal wall.

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