Tracheoinnominate Artery Fistula

This case was written by Dr. Brandon Evtushevski. Dr. Evtushevski is an Emergency Medicine resident at the University of British Columbia, Vancouver Island Site. Prior to this, he completed a BSc in Neuroscience at McGill University followed by his MD at the University of British Columbia. He has interests in neurologic emergencies, critical care and medical education, particularly through the ever-expanding FOAMed world.


Tracheostomy patients are infrequently seen in the emergency department, leading to an unfamiliarity around important anatomical considerations and tracheostomy hardware management. These individuals can harbour acutely life-threatening pathology, with the most feared being the tracheoinnominate artery fistula. This diagnosis requires a high level of suspicion and a sequence of rapid interventions to protect the airway from on-going hemorrhage, temporize the bleeding via a HALO procedure (Utley maneuver), and stabilize the patient for definitive OR management. The team leader’s crisis resource management skills will be strained in this case given the multitude of serious competing life-threats, navigation of unfamiliar and complex airway anatomy, and the utilization of a HALO procedure.


EMS called by partner after spontaneous frank red blood per tracheostomy tube 40 min ago. Stopped on initial assessment but now increased red blood output again on route to hospital. Difficulty breathing, agitated. 10 minutes out.


A 50-year-old male with a recently placed tracheostomy presents to the emergency department following sudden onset, brisk bleeding from his tracheostomy tube. He is in distress with on-going bleeding and hemodynamic instability. The team leader needs to identify the importance of immediate definitive airway control and on-going hemorrhage resuscitation with the most likely culprit being a tracheoinnominate artery fistula. A high-acuity, low opportunity (HALO) procedure – Utley maneuver – will be utilized as salvage therapy to temporize the patients bleeding. Early consultation with surgical colleagues for definitive hemorrhage control is paramount. 


Source = Image source: K. Inaba. “Bleeding Tracheostomy” Essentials of Emergency Medicine, Live Presentation. Sept 20, 2016. 

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