Bleeding from the brachiocephalic trunk in tracheal surgery: whether the patient has a chance?

Bleeding from the brachiocephalic trunk is a rare and dangerous complication, and the lack of surgical treatment leads to the fatal outcome in most cases. It is necessary to distinguish the rupture of the brachiocephalic trunk due to mechanical trauma from the erosive injury occurring due to ischemia of the artery wall. Rupture of the brachiocephalic trunk may occur during surgery or result from a trauma. Erosion of the brachiocephalic trunk wall can occur after surgery on the organs of the neck and mediastinum in the period from several days to several months. Currently, there is no standard of care for the management of patients with bleeding from the brachiocephalic trunk. We present a clinical observation of a successful multidisciplinary interaction in the treatment of a patient with a severe extended tracheal stenosis, whose reconstructive surgery on the trachea was accompanied by a circular rupture of the brachiocephalic trunk and a massive bleeding.
Description of the clinical observation. The article presents a clinical case of two-stage treatment of a patient with a rupture of the brachiocephalic trunk during tracheal reconstruction, which was subsequently complicated by mediastinitis, the formation of an aneurysm near the brachiocephalic trunk prosthesis, aortic-mediastinalbronchial-pulmonary fistulas, and recurrent hemoptysis. Urgent sternotomy allowed to stop bleeding from the brachiocephalic trunk, and replacing it with a synthetic prosthesis allowed saving the patient from bleeding and neurological disorders. Subsequently, the patient underwent stage-by-stage removal of the brachiocephalic trunk prosthesis, removal of the aortic defect with a synthetic prosthesis, removal of the infected mediastinal hematoma using artificial blood circulation and circulatory arrest, separation of the aortic-mediastinal-bronchial-pulmonary fistulas, mediastinal omentoplasty and removal of the tracheal defect on the endoprosthesis. This treatment made it possible to remove the aortic-mediastinal-bronchial-pulmonary fistulas, reliably isolate the patch on the aorta, ensure a safe course of the postoperative period, and led to early social rehabilitation of the patient.
Conclusion. Emergency manipulation for bleeding from the brachiocephalic trunk includes finger pressing of the artery to the sternum, sternotomy and ligation of the artery. Alternatively, it is possible to use a synthetic vascular prosthesis or autovein for reconstruction with subsequent isolation of the anastomosis by the pedicle muscle flap or to perform the mediastinal omentoplasty to protect against secondary infection. With linear defects of the brachiocephalic trunk, it is possible to reconstruct it by suturing or installing a stent, but endovascular techniques have their own negative consequences. In all cases, there is a high risk of re-bleeding due to secondary infection, especially in patients with a functioning tracheostomy. Therefore, we argue that tracheostoma removal is the key to successful treatment of patients in this group, as the tracheostoma presents the main source of infection and the cause of mediastinitis, and if the removal is impossible — the maximum separation of a tracheostoma from the vessels should be done using a volumetric pedicle flap, with a multidisciplinary approach and an instant decision on sternostomy and elimination of the bleeding source, ensuring airway patency and anesthetic protection of the brain at all stages of the operation.
Key words: rupture of the brachiocephalic trunk, hemorrhage, erosion of the brachiocephalic trunk, mediastinalbronchial-pulmonary fistulas, mediastinal hematoma
Conflicts of interest. The authors have no conflicts of interest to declare.
Funding. There was no funding for this study.