DISCUSSION
Any significant bleeding following tracheostomy, either immediate or delayed is a potential life-threatening complication. Peak incidence and the risk for bleeding is found during the first 6 weeks after surgery6. Most of delayed postoperative bleedings are the result of TIAF, and in more than 50% of cases, a sentinel bleeding occurs. Risk factors associated with an increased risk for TIAF are low tracheal ring incisions (lower than 3rd ring), which lead to cannula-induced constant arterial pressure, surgical site infection and overinflated cuff that can cause pressure necrosis to the tracheal wall 6.
Surgery to control early and delayed postoperative bleeding in general, and specifically in cases of TIAF, is still considered the treatment of choice. Ligation or resection of the innominate artery and repair of the fistula is usually performed via a median sternotomy approach, with the use of grafts if needed7. Complications following surgery include cerebral hypoperfusion that may lead to stroke, graft infection, high risks of re-bleeding and poor survival rates. Wang et al , reported a 7% 1-year survival rate following a surgical TIAF repair 8.