Case Reports in Medicine Figure 5: Intraoperative view. The innominate artery (white arrow) was isolated and taped proximally and distally. diversion and occurring within 2-3 weeks of these procedures [6–8]. Although the mechanism of TIF is not clear, several factors are implicated, including pressure on the trachea from the adjacent innominate artery, which is exacerbated by scoliosis and pressure necrosis of the tracheal wall from the tracheostomy tube [3, 8, 9]. Progressive scoliosis induces narrowing of the mediastinum that results in the compression of the innominate artery against the trachea [10, 11]. Since hemorrhage from TIF is often diﬃcult to control and is frequently fatal, preventive procedures are recom- mended to avoid this complication. Low tracheostomy placement (below the 4th tracheal ring) and excessive cuﬀ pressure should be avoided [3, 8, 9]. Modern soft, ﬂexible tracheostomy tubes are useful to prevent excessive pressure on the tracheal wall [3]. Once TIF has developed, successful management de- pends on early diagnosis and management. Immediate management includes minimizing blood loss using digital pressure and overinﬂation of the tracheostomy cuﬀ over the bleeding point after securing the airway [8, 9, 12, 13]. In gen- eral, neurologically impaired patients are smaller than those who are neurologically intact, and digital pressure control of bleeding is quite diﬃcult because of the small tracheotomy opening. Deﬁnitive control of hemorrhage requires surgical intervention or an endovascular technique to access the bleeding site. With recent developments in endovascular instruments, endovascular stent graft treatment of TIF has been reported [14]. The survival rate of TIF is reported to be less than 30%, even with surgical intervention [4, 11]. Periodic tra- cheoscopy is therefore important to detect early signs of TIF, particularly for cases with herald bleeding from the tracheostomy, presenting as hemoptysis or blood on suction [9]. A deﬁnitive indication for surgical treatment is bleeding from TIF, and most surgical interventions are performed after TIF formation. Prophylactic surgical intervention for TIF has been described less frequently. Iodice et al. reported prophylactic ligation of the innominate artery for 7 patients with neuromuscular disorders who had already been tra- cheostomized [3]. Tanaka and Iwanaka reported one neu- rologically impaired patient who underwent simultaneous 3 ligation of the innominate artery and tracheoesophageal diversion [15]. Prophylactic preoperative and postoperative antibiotics were used to prevent mediastinitis. We consider that the present case had a high risk of TIF formation because the innominate artery was already encroaching on the trachea, hence long-term intubation was anticipated. The intubation tube should be placed beyond the encroaching innominate artery because of tracheal stenosis. In these circumstances, the encroaching innominate artery rubbed by the intubation tube had risk of developing TIF. A rate of future TIF formation for this patient without the ligation of innominate artery is not anticipated, but might be higher than a patient of no encroaching innominate artery in the trachea lumen. Allan and Wright reported the safety and reliability of ligation of the innominate artery [16]. Despite the reverse ﬂow in the right internal carotid artery after ligation of the innominate artery, symptoms of subclavian steal have not been reported. Many of ligations of the innominate artery were performed as emergency procedures, and no time for checking an appearance of a circle of Willis. Preoperative examination of a circle of Willis is a prerequisite for the case of planning prophylactic ligation of the innominate artery. In the case of an occlusion of circle of Willis, revascularization to preserve the right carotid and right subclavian artery ﬂow should be considered. We do not propose ligation of the innominate artery as a routine prophylactic procedure at tracheostomy for all neurologically impaired patients. The treatment of TIF under emergency conditions was not really successful, and we believe that prophylactic ligation is a valid procedure for patients at high risk of developing TIF and helped to restore the patient’s condition. 4. Conclusion Although prophylactic ligation of the innominate artery might be the most eﬀective and least invasive surgical intervention to prevent TIF, it is not a routine procedure for patients with tracheostomy and tracheoesophageal diversion. Nonetheless, it might be considered a valid option for patients at high risk of developing TIF. References [1] L. Kapural, J. Sprung, I. Gluncic et al., “Tracheo-innominate artery ﬁstula after tracheostomy,” Anesthesia and Analgesia, vol. 88, no. 4, pp. 777–780, 1999. [2] C. B. Ross and J. A. Morris, “Tracheo-innominate artery ﬁstula: a potentially fatal complication of tracheostomy,” Journal of the Tennessee Medical Association, vol. 81, no. 7, pp. 446–448, 1988. [3] F. Iodice, G. Brancaccio, A. Lauri, and R. Di Donato, “Preventive ligation of the innominate artery in patients with neuromuscular disorders,” European Journal of Cardiothoracic Surgery, vol. 31, no. 4, pp. 747–749, 2007. [4] O. P. Schaefer and R. S. Irwin, “Tracheoarterial ﬁstula: an unusual complication of tracheostomy,” Journal of Intensive Care Medicine, vol. 10, no. 2, pp. 64–75, 1995. [5] K. Takasaki, K. Enatsu, M. Nakayama, T. Uchida, and H. Takahashi, “A case with tracheo-innominate artery ﬁstula: