Preemptive Surgical Strategies for Impending Tracheo-Innominate Artery Fistula: A Case Series of Three High-Risk Patients

Tracheo-innominate artery fistula (TIF) is a rare but catastrophic complication of tracheostomy with extremely high mortality after rupture. No established guidelines exist for preemptive intervention in impending TIF. We report 3 high-risk patients with objective imaging and/or bronchoscopic warning signs who underwent individualized preemptive surgical management. Risk assessment included computed tomography or magnetic resonance imaging, bronchoscopy, and intraoperative cerebral perfusion monitoring during temporary innominate artery clamping. Strategies included muscle interposition, ligation, or intrathoracic bypass reconstruction. All patients recovered without neurological complications, and no TIF occurred during follow-up. Preemptive intervention may be considered only in carefully selected patients with objective warning signs.