Tracheoinnominate fistula in patients with bovine arches: An under-reported risk factor for a catastrophic complication.

Objectives: Tracheoinnominate fistula (TIF) is a rare but frequently fatal complication of tracheostomy. This study aims to describe a case series of TIFs associated with high-riding innominate arteries and bovine arch anatomy, and highlight anatomic variants as under-recognized risk factors that may warrant modified perioperative planning and surveillance. Methods: A focused literature review was conducted to contextualize known risk factors, operative approaches, and management strategies for TIFs. This retrospective case series at a single institution reviews three patients at risk for development of TIFs with one case of established TIF. Clinical presentation, imaging findings, arch anatomy, operative management, and outcomes were analyzed. Results: All three patients demonstrated bovine arch anatomy with a high-riding innominate artery traversing the trachea at a more cephalad level than typical anatomy. Two patients presented with sentinel bleeding or tracheal erosion suggestive of impending TIF and were successfully managed with early surgical intervention, vascular control, and tissue interposition. One patient presented with a fully developed TIF and catastrophic hemorrhage requiring emergent innominate artery ligation and tracheal debridement, ultimately resulting in mortality. Imaging demonstrated loss of the normal fat plane between the trachea and innominate artery, correlating with intraoperative findings. Conclusions: Bovine arch anatomy may represent an underappreciated anatomic risk factor for TIF development due to its association with a high-riding innominate artery. Routine review of preoperative imaging, heightened surveillance, and consideration of preventative strategies in high-risk patients may improve early detection and reduce morbidity and mortality associated with this catastrophic complication.