Erosion of the anterior tracheal wall overlying the brachiocephalic artery, either due to necrosis from a high-pressure cuff or ulceration by an angulated tip of a tracheostomy tube, is now rarely seen (see Figure 27-1B). In these cases, the stoma is usually at a more nearly correct level, high in the trachea. In emergency, it is not possible or advisable to expose the fistula by finger dissection or by cutting down to it in order to place a tam-ponading finger on the artery, since the fistula usually occurs 1 to 4 weeks after tracheostomy. The pathology lies entirely within the mediastinum and not at the stomal level. This is also the case in stent induced hemorrhage. Bleeding is controlled initially by overinflating the tracheostomy cuff and then by inserting an endo-tracheal tube and inflating the cuff with high pressure to tamponade the fistula (see Figure 27-2B).
Exposure is obtained as described previously. If the lesion has resulted from erosion by a high-pressure cuff, then there is usually circumferential damage to the trachea at the cuff level (Figure 27-4A). Control of the artery is achieved as previously described and the damaged segment of artery is excised.
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