Multidisciplinary Team‐Assisted Rescue of Innominate Artery Hemorrhage During Tracheotomy for Bilateral Vocal Cord Paralysis Post‐Thyroidectomy for Thyroid Cancer: A Case Report and Scoping Literature Review

ABSTRACT

Objectives

The purpose of this study is to present a case of innominate artery (IA) rupture during tracheotomy, along with its prevention and emergency management. We also conducted a scoping review of the literature on IA hemorrhage during tracheotomy.

Methods

Here we describe a case of bilateral vocal cord paralysis after thyroid cancer surgery that developed sudden massive hemorrhage during tracheotomy under local anesthesia. In this study we also compare it to the 12 cases reported in the literature in terms of clinical presentations, reasons of IA injury, immediate hemostatic measures, treatment strategy, postoperative complications, and follow up.

Results

Our case is a 39‐year‐old male with a history of thyroid cancer surgery 14 months ago. He presented with worsening hoarseness and exertional dyspnea. He was diagnosed with grade II laryngeal obstruction and bilateral vocal cord paralysis and admitted for surgical airway management. Sudden massive hemorrhage occurred during tracheotomy under local anesthesia. The multidisciplinary team (MDT) was activated, including anesthesiology and vascular surgery. Emergency angiography revealed active bleeding at the IA bifurcation. A covered stent was successfully deployed. The patient subsequently underwent CO₂ laser posterior cordotomy three times to widen the glottic gap. At 32‐month follow‐up, the patient had no dyspnea, mild hoarseness, and no neurological deficits.

Conclusion

This case highlights the need for preoperative imaging, prompt multidisciplinary intervention, and the utility of endovascular stenting in managing high‐risk tracheotomy complications.

1. Introduction

Although tracheo‐innominate artery fistula (TIF) is a well‐recognized postoperative complication of tracheostomy, innominate artery (IA) injury during tracheostomy is rare but potentially fatal, often resulting in massive hemorrhage and high mortality. Risk factors include a high‐riding innominate artery (HRIA) [1, 2, 3], altered neck anatomy due to multiple surgeries, medial displacement of vascular structures after thyroidectomy, short neck anatomy requiring low tracheostomy, and penetrating neck trauma [4].

When rupture of the IA occurs intraoperatively, emergency management is required. Reported treatment approaches include median sternotomy with direct repair or ligation of the injured vessel, as well as endovascular embolization or stent graft placement. In this report, we present a case of IA rupture during tracheotomy in a patient with bilateral vocal cord paralysis following multiple surgeries for bilateral thyroid cancer. The bleeding was successfully controlled with emergency endovascular stent placement.

The patient subsequently underwent multiple laser posterior cordotomies to relieve airway obstruction due to vocal cord paralysis. This case illustrates key considerations for the prevention and emergency management of vascular injury in patients with complex neck surgical histories. We also review the relevant literature to highlight the role of multidisciplinary team (MDT) management in improving outcomes for patients with tracheostomy‐related vascular complications.

The combination of a HRIA and a history of extensive thyroid and neck surgeries presents a particularly rare and high‐risk surgical scenario. To our knowledge, few reports have detailed emergency tracheotomy complicated by HRIA rupture in a patient with such significant anatomical distortion due to prior bilateral thyroid cancer surgeries. The altered vascular–tracheal relationship, compounded by fibrotic tissue planes, makes both tracheal identification and bleeding control uniquely difficult. This case therefore provides novel insight into managing these compounded risks, emphasizing the need for individualized surgical planning and real‐time multidisciplinary coordination.

2. Methods

A case of IA rupture during tracheotomy, its prevention and emergency management.

Review of literature through a search across different search engines (Pubmed and Web of Science) using the following terms: (((injury) OR (bleed) OR (hemorrhage) OR (rupture)) AND ((innominate artery) OR (brachiocephalic artery)) AND (tracheostomy)) NOT ((tracheo‐innominate artery fistula) OR (tracheo‐arterial fistula) OR (carotid‐tracheal fistula) OR (TIF) OR (fistula) OR (tracheo‐arterial erosion)). We obtained 8 case reports and series in English that included a total of 9 cases that reported the management for IA rupture between the years 1965 and 2025. We also obtained 3 case reports from citation searching.

This study was approved by the Institutional Review Board of the First Affiliated Hospital, Zhejiang University School of Medicine. Written informed consent was obtained from the patient for participation and for publication of this case report and accompanying clinical information and images.

3. Case Report

A 39‐year‐old man presented with worsening hoarseness and exertional dyspnea 14 months after undergoing bilateral radical thyroidectomy, right neck dissection (levels II–V), and parathyroid autotransplantation for thyroid cancer. Intraoperatively, the right recurrent laryngeal nerve was encased by tumor, surgically transected, and repaired. Postoperatively, the patient experienced mild hoarseness and occasional aspiration when drinking, without dyspnea.

Two and a half months later, he underwent a second‐stage left neck dissection. Nine months after this second surgery (i.e., 2 months before admission), he developed worsening exertional dyspnea and hoarseness. At rest, symptoms were mild, but he reported inspiratory stridor and shortness of breath with minimal exertion, without difficulty sleeping or eating, and without any signs of oxygen deprivation. Laryngoscopy revealed bilateral vocal cord paralysis with glottic narrowing (~0.2 cm gap; Figure 1A). As grade II laryngeal obstruction refers to laryngeal airway narrowing that causes mild inspiratory dyspnea at rest, which worsens with physical activity, but does not interfere with sleep or eating, and is not associated with obvious hypoxia, he was diagnosed with grade II laryngeal obstruction and bilateral vocal cord paralysis, and was admitted for surgical airway management.

FIGURE 1.

(A) Laryngoscopy showing restricted bilateral vocal cord abduction. (B) Superselective angiography revealing active extravasation at the bifurcation of the IA (arrow: Bleeding site; arrowhead: Contrast leakage into surrounding tissue). (C) Deployment of a 13 × 50 mm GORE VIABAHN covered stent spanning from the brachiocephalic artery to the right common carotid artery (arrow: Covered stent). (D) Post‐deployment balloon dilation with a 7 mm balloon (arrow: Balloon). (E) Follow‐up angiography demonstrating no contrast extravasation and preserved stent patency (arrow: Blood flow through stent). (F) Interruption of blood flow in the right subclavian artery due to stent coverage (arrow: Flow interruption).

A tracheotomy under local anesthesia was planned, followed by CO₂ laser posterior cordotomy under general anesthesia. A transverse incision was made along the prior surgical scar. Dense fibrous tissue and distorted anatomy from previous surgeries obscured landmarks, and the trachea was non‐palpable. During dissection of the right cervical tissue, sudden massive hemorrhage occurred. Gauze compression controlled the bleeding temporarily while the team calmed the agitated patient.

Using the thyroid cartilage as a landmark, the trachea was identified, and an incision was made between the 2nd and 3rd tracheal rings. An endotracheal tube was inserted, and general anesthesia was induced. Given the bleeding pattern, injury to the IA was suspected. The MDT was activated, including anesthesiology and vascular surgery. The patient was immediately transferred to a hybrid OR for angiography.

Via right brachial artery access, superselective angiography confirmed active extravasation at the bifurcation of the IA (Figure 1B). A 13 × 50 mm GORE VIABAHN covered stent was deployed, bridging the brachiocephalic trunk and the right common carotid artery (Figure 1C), with balloon dilation using a 7 mm balloon (Figure 1D). Post‐procedural angiography showed no further extravasation and good stent patency (Figure 1E). However, flow in the right subclavian artery was interrupted (Figure 1F).

The patient then underwent CO₂ laser posterior cordotomy of the right vocal cord. Intraoperatively, the glottic gap was ~0.1 cm. The posterior right vocal cord and vocal process were partially excised, widening the airway. On postoperative days 1–2, he experienced brief exertion‐related syncope with transient loss of consciousness. No neurological deficits were observed. The episode was attributed to subclavian steal syndrome, secondary to right subclavian artery occlusion. Symptoms resolved by postoperative day 3.

Retrospective review of preoperative contrast‐enhanced CT revealed the brachiocephalic artery coursing > 2 cm above the sternal notch, anterior to the trachea—consistent with an HRIA (Figure 2). Follow‐up CT angiograms confirmed proper stent position, good perfusion, and no signs of thrombosis, stenosis, or dissection (Figure 3).

FIGURE 2.

Contrast‐enhanced CT images of the neck pre‐tracheotomy and pre‐thyroidectomy showing: (A) The brachiocephalic artery located lateral to the thyroid gland. (B) The artery positioned > 2 cm above the sternal notch, crossing anterior to the trachea—consistent with a HRIA. Post‐thyroidectomy scans show: (C) Medial displacement of the brachiocephalic artery, abutting the right tracheal wall. (D) An elevated course with increased distance from the suprasternal notch compared to pre‐tracheotomy imaging.

FIGURE 3.

Postoperative follow‐up cervical CTA showing: (A, B) A well‐positioned covered stent in the right brachiocephalic artery with full expansion and adequate contrast filling (arrow: Stent). (C, D) Normal anatomy and flow in the common carotid arteries, internal and external carotid arteries, vertebral arteries, and basilar artery.

At 7 and 29 months postoperatively, the patient underwent additional CO₂ laser posterior cordotomies to further widen the glottic gap (Figure 4). He remained able to occlude the tracheostomy tube without dyspnea. At the 32‐month follow‐up, the patient was free of respiratory symptoms, with only mild hoarseness and no neurological deficits.

FIGURE 4.

Laryngoscopic images after CO₂ laser cordotomy: (A) At 1.5 months and (B) 4 months following the first procedure. (C) At 3 months and (D) 17 months following the second procedure, showing progressive glottic widening and improved airway patency.

In the present case, the patient underwent multiple CO₂ laser posterior cordotomies to relieve airway obstruction due to bilateral vocal cord paralysis. Staged cordotomies were necessary because the initial procedure only partially widened the glottic gap, and persistent exertional dyspnea required additional interventions to achieve adequate airway patency. This approach was preferred over alternatives, such as arytenoid lateralization, arytenoidectomy, posterior cricoid or glottic expansion/laryngoplasty, and permanent tracheostomy, because it allowed incremental airway expansion, minimized tissue trauma, preserved laryngeal structure, and avoided long‐term tracheostomy dependence, particularly in a patient with prior multiple neck surgeries. The staged laser cordotomies thus provided an effective balance between airway safety and functional voice preservation.

The study protocol was approved by the Institutional Review Board of our university hospital, and written informed consent for publication was obtained from the patient.

4. Review

This review found 29 articles in PubMed and 25 in Web of Science. The total number was 54 articles. A total of 20 articles were excluded because they were duplicates between the databases. A total of 22 were excluded because they were out of the scope of our intended topic, and 4 articles were excluded because no abstract was available. We also obtained three case reports from citation searching. A total of 11 articles were included in this review (Figure 5). Table 1 summarizes the reviewed cases in this paper.

FIGURE 5.

Flow chart: Identification of studies via databases and other methods.

TABLE 1.

Summary of clinical presentations, diagnosis, proposed surgical procedure, type of IA injury, immediate hemostatic measures, treatment strategy and outcome of patients with IA hemorrhage.

No.	Study	Cases	Age (years, sex)	Past medical history	Past surgical history	Symptoms and diagnosis	Proposed surgical procedure	Reason of IA injury	Anatomical abnormality of IA	Immediate hemostatic measures	Treatment strategy	Postoperative complications	Follow up period and status
1	Present case	1	39, M	Thyroid cancer	Bilateral radical thyroidectomy + right ND 14‐month ago, left ND 2.5‐month ago	Worsening hoarseness, exertional dyspnea; grade II laryngeal obstruction; bilateral vocal cord paralysis	Tracheotomy under local anesthesia; CO2 laser posterior cordotomy under general anesthesia.	Electrosurgical injury at IA bifurcation with massive hemorrhage during tracheotomy under local anesthesia	HRIA	Bleeding temporarily controlled by Direct gauze compression	MDT activated (anesthesiology, vascular surgery); angiography showed active bleed at innominate bifurcation; covered stent placed bridging innominate–right CCA	Right subclavian flow interrupted; transient exertional syncope on postoperative days 1–2, which was resolved on postoperative day 3	32‐month, alive, mild hoarseness
2	Keene and Edwards [5]	1	51, F	Asthma and diabetes	Tracheostomy 2 years ago	Tracheal stenosis	Gastric tube placement; tracheal stenosis repair	IA laceration with severe hemorrhage during tracheal dissection	None	Direct digital pressure	Median sternotomy; IA clamped proximally and distally and repaired	Left pneumothorax with ETT in right main bronchus; small residual stenosis near right ICA; several febrile episodes	21‐day, alive
3	Filatoff et al. [6]	1	17, M	Motor vehicle accident 8 months ago; C6 paraplegia; tracheal stenosis after prior tracheostomy	ORIF of the right femur, several tracheostomy revisions including T‐tube placement (removed two‐week prior), multiple laser ablation procedures to correct tracheal stenosis	Mild shortness of breath at rest; dyspnea on exertion; tracheal stenosis	Tracheostomy	Low tracheostomy below 4th ring (below stenosis); lateral extension caused IA injury with severe hemorrhage	None	Direct pressure	Median sternotomy; IA bleed identified and controlled	Ventricular tachycardia/fibrillation treated with open cardiac massage and defibrillation; coagulopathy and hypothermia managed with rewarming, FFP, platelets, and cryoprecipitate	23‐day, alive, neurologically intact
4	Manjunath et al. [4]	1	40, M	Blunt trauma to face, neck, and chest	None	Profuse oral/nasal bleeding, coughing blood, gasping, aphonia; threatened airway; massive tracheolaryngeal injury with orofacial trauma and cervical tenderness	Cricothyroidotomy performed; oxygenation not maintained; transferred to OR for tracheostomy	Forceful bleeding during tracheostomy; packing ineffective; IA injury	Anomalous IA course arching midline anterior to trachea above sternum	Packing ineffective; vascular forceps applied for hemostasis	High tracheostomy at 1st–2nd rings for airway clearance and ETT placement; right‐sided trap door procedure for exposure; injured IA repaired	Eroded tracheal rings, massive blood aspiration, and TIF	14‐day, sudden massive oronasal and tracheal bleeding during extubation; died from hypoxic arrest
5	Brahmbhatt et al. [7]	1	57, M	CAD, ICM, anemia, DM with neuropathy	Left below‐knee amputation for foot osteomyelitis	MRSA pneumonia; MDR UTI; septic shock with hypotension; HRF on prolonged ventilation	PDT	PDT via midline incision (2nd–3rd rings); IA laceration with bleeding during No. 8 tube insertion	None	None	Hemorrhage controlled with vertical mattress sutures; transfused 6 units PRBCs	IA pseudoaneurysm, which was repaired 2 days later	Died from multi‐organ failure after prolonged hospitalization
6	Sharma et al. [8]	1	69, F	TBI	None	In view of poor neurological recover	PDT	Tract dilated by Seldinger technique; No. 7 tracheostomy tube insertion caused IA injury with profuse bleeding	HRIA	Balloon inflated, bleeding stopped immediately	Superficial oblique IA found intraoperatively; brisk bleeding after tube removal; defect repaired with 6/0 Prolene under proximal control; tracheostomy completed	None	No follow‐up, alive
7	Barranco et al. [9]	1	60, F	Cardiorespiratory arrest; right coronary acute occlusion	Right coronary angioplasty and stent placement	Unconscious despite pharmacologic sedation	Endoscopic tracheostomy with Griggs method (PDT)	Improper use of Howard–Kelly forceps caused mediastinal entry and traction injury with 3 cm aortic arch rupture between IA and left CCA ostia	None	None	None	None	Died despite resuscitation efforts
8	Yohei et al. [10]	1	79, M	Terminal right upper lobe lung cancer; intubated for 3 weeks after accidental airway obstruction	None	Intubated for 3 weeks	Bedside surgical tracheostomy	Continuous arterial bleeding during procedure; injury to IA and right CCA	Right tracheal shift from lung cancer adhesions; IA coursing anterior to 3rd tracheal ring	Direct finger compression	Right clavicular head resected; repair and graft interposition of the arteries failed due to atherosclerosis; IA, right carotid, and subclavian arteries ligated after confirming collateral flow	None	7‐day, transferred to subacute hospital, alive
9	Magdalena al. [11]	1	66, M	Coronary heart disease, hyperlipidemia; recurrent cardiac arrests due to MI and VF; resuscitated but remained unconscious (GCS 3–4); anoxic encephalopathy	Emergency PCI with two stents in left circumflex artery for STEMI	Poor general condition (GCS 3); intubated, mechanically ventilated; no pupillary or corneal reflexes	PDT under bronchoscopic guidance	Hours after PDT, profuse bleeding around tube; dissection revealed V‐shaped 1.5 cm tear on posterior IA wall (~2 cm above aortic arch, ~1.8 cm below bifurcation); tracheotomy between 7th–8th rings	None	None	Intubated, mechanically ventilated; received CPR and 4 U PRBC	None	Died after 1.5 h of resuscitation
10	Agyei et al. [12]	1	71, M	Thymic cancer	Not mentioned	Not mentioned	Tracheotomy	Pseudoaneurysm of proximal right CCA from pressure/friction with tracheostomy	None	None	Balloon‐expandable covered stent deployed with simultaneous compliant balloon inflation at right subclavian origin (kissing‐balloon technique) at distal IA	None	No follow‐up, alive
11	Sugisawa et al. [13]	1	40, M	Cholecystolithiasis	None	Laryngeal edema secondary to intubation during anesthesia induction	Urgent tracheostomy	Traumatic IAA secondary to urgent tracheostomy	None	Manual pressure	Axillo‐axillary bypass with coil embolization of IA	None	More than 5‐year, alive
12	Sargunaraj et al. [14]	2	60, F	Grade IV tracheal stenosis post‐TBI ventilation	Tracheostomy for grade IV tracheal stenosis	Aphonia and cannulated for 3 years; tracheal stenosis	Tracheal resection and anastomosis; post‐extubation stridor from supraglottic edema, nasotracheal stent placed; emergency tracheostomy after failed stent removal	Tear at origin of CCA from IA involving two‐thirds circumference	IA origin and bifurcation located left of midline (~11 mm); tortuous 2 cm course before bifurcation; right CCA originated 17 mm left of sternoclavicular joint, adherent to anterior tracheal wall below tracheostoma	Manual compression	IA tear repaired with primary suturing; tracheostomy completed	None	Regular follow‐up, alive.
13			47, M	Severe stridor; tracheal stenosis after prolonged ventilation for organophosphorus poisoning	Emergency tracheostomy; Repeated balloon dilatations	Tracheal stenosis	Tracheal resection and anastomosis	Irregular laceration on inferior IA during tracheal dissection; superior surface adherent to anterior tracheal wall	IA (4.2 cm) with anomalous horizontal course; closely adherent to anterior tracheal wall in suprasternal region; bifurcated 1.5 cm above right sternoclavicular joint at tracheal right border	Manual pressure	Sternotomy; tear repaired with left internal jugular vein graft (IA–right CCA) reinforced by strap muscle sling	TIF, which was treated with two covered stents in IA extending to right subclavian and right CCA	Regular follow‐up, alive.

Abbreviations: IA: innominate artery; F: female; M: male; ND: neck dissection; HRIA: high‐riding innominate artery; CCA: common carotid artery; ETT: endotracheal tube; ICA: internal carotid artery; ORIF: open reduction and internal fixation; FFP: fresh frozen plasma; OR: operating room; CAD: coronary artery disease; ICM: ischemic cardiomyopathy; DM: diabetes mellitus; MRSA: methicillin‐resistant staphylococcus aureus ; MDR: multidrug‐resistant; UTI: urinary tract infection; HRF: hypoxic respiratory failure; PDT: percutaneous dilatational tracheostomy; PRBCs: packed red blood cells; TBI: traumatic brain injury; IAA: innominate artery aneurysm; TIF: tracheo‐innominate fistula; MI: myocardial infarction; VF: ventricular fibrillation; GCS: Glasgow Coma Scale; PCI: percutaneous coronary intervention; STEMI: ST segment elevation myocardial infarction; CPR: cardiopulmonary resuscitation.

A total of 13 cases of IA injury or hemorrhage associated with tracheostomy or tracheal surgery were identified, including 1 present case and 12 cases described in 11 published reports from 2001 to 2021. Patients ranged in age from 17 to 79 years (median 57 years), and most were male (nine men, four women). Many patients had systemic comorbidities including thyroid carcinoma, diabetes mellitus [5, 7], traumatic brain [8, 14] or spinal injury [6], coronary artery disease [7, 9, 11], or malignancy [10, 12]. Most also had a clear surgical history, and five had previously undergone neck or tracheal procedures such as thyroidectomy, tracheostomy [5, 6, 14], or tracheal stenosis repair [6, 14], which significantly increases the risk of IA injury during tracheostomy.

Airway compromise was the dominant clinical presentation. The typical symptoms were stridor, dyspnea, or aphonia, often prompting tracheostomy for airway obstruction or ventilatory dependence. The procedures most frequently associated with IA injury were tracheostomy in seven patients [4, 6, 10, 12, 13, 14], percutaneous dilatational tracheostomy (PDT) [7, 8, 9, 11] in four patients, and other airway operations such as tracheal stenosis repair in one patient [5] and tracheal resection and anastomosis in one patient [14]. In several cases, the procedures were performed under local anesthesia due to high airway risk [10, 13, 14].

Mechanistically, direct mechanical or electrosurgical trauma was the predominant cause during tracheostomy or dissection, including electrocautery burns at the IA bifurcation, laceration during tracheal incision extension or tearing during tracheal dissection [5, 14]. Four sustained iatrogenic ruptures during PDT [7, 8, 9, 11]. One patient experienced traction injury from instrument misplacement (Howard–Kelly forceps) during PDT [9], while two developed pressure‐ or friction‐induced pseudoaneurysms or aneurysms during tracheotomy [7, 12]. Two cases were emergency tracheostomies [13, 14]. Two cases had a low tracheostomy site, one below the 4th ring [6] and another between the 7th–8th rings [11]. Anatomical variations were present in six cases, predominantly high‐riding or horizontally coursing IA segments lying immediately anterior to the trachea and sternum [4, 8, 10, 14]. Such anomalies greatly increased the likelihood of vascular injury, particularly when the airway incision extended below the fourth tracheal ring or within scarred operative fields.

Emergency hemostatic maneuvers were variably effective. Manual or digital compression was the most common first‐line measure (seven cases) [5, 6, 10, 13, 14], while balloon inflation provided temporary control in one case [8]. In rapidly exsanguinating patients, bleeding could not be arrested before definitive intervention, yet these temporizing methods were often crucial in buying time for subsequent surgical or endovascular management, especially when multidisciplinary coordination was available.

Definitive treatment approaches reflected the evolution of vascular control strategies over the two decades reviewed. Seven patients underwent open repair via sternotomy or direct exposure, including proximal and distal clamping with primary suturing (Cases 2 [5], 3 [6], and 6 [8]), direct closure of the defect (Cases 4 [4], 5 [7], and 12 [14]), or venous interposition graft reconstruction (Case 13 [14]). One of these (Case 5 [7]) required secondary surgery for pseudoaneurysm after initial vertical‐mattress hemostasis. Four patients received endovascular or hybrid therapy, such as covered‐stent placement bridging the IA and right common carotid artery (Cases 1 and 10 [12]), axillo‐axillary bypass with coil embolization (Case 11 [13]), or endovascular management of a TIF with dual covered stents (Case 13 [14]). The present case illustrates successful MDT‐guided endovascular repair that rapidly restored vessel integrity while minimizing invasiveness. In one further case (Cases 8 [10]), severe atherosclerosis or unstable hemodynamics precluded repair, and the IA, right carotid, and subclavian arteries were ligated after confirmation of adequate collateral cerebral flow.

Postoperative complications varied. Vascular sequelae included right‐subclavian flow interruption, IA pseudoaneurysm formation [7], and TIF [4]. Cardiopulmonary complications such as ventricular tachycardia/fibrillation [6], left pneumothorax [5], and transient exertional syncope were reported, together with coagulopathy and mild residual hoarseness. Despite the high lethality of IA hemorrhage, overall survival was 69% (nine of 13 patients). Four deaths resulted from uncontrollable bleeding [9, 11], hypoxic cardiac arrest [4], or multi‐organ failure after prolonged hospitalization [7]. Survivors generally achieved good long‐term recovery without recurrent hemorrhage or neurological deficit, with follow‐up durations ranging from 1 week to more than 5 years.

Collectively, these cases demonstrate that IA injury during tracheostomy or airway surgery, though rare, is catastrophic. Predisposing factors include prior cervical operations, anomalous arterial course, and procedures performed below the fourth tracheal ring. Rapid recognition and immediate compression or balloon tamponade are essential first responses, followed by activation of an MDT to plan definitive repair. The growing application of endovascular techniques offers an effective, minimally invasive alternative to open repair, achieving prompt hemostasis and vessel preservation. Early diagnosis, coordinated multidisciplinary management, and individualized treatment remain the key determinants of survival.

5. Discussion

5.1. High‐Riding Innominate Artery (HRIA)

The IA, or brachiocephalic artery, is the first major branch of the aortic arch. It typically ascends along the right side of the trachea and bifurcates into the right subclavian and right common carotid arteries at the level of the right sternoclavicular joint [15]. An HRIA is a rare anatomical variant, with an estimated incidence of approximately 0.32%. In a CT‐based study of 829 patients, Cai et al. reported that in 26.4% of cases, the superior border of the IA was located above the suprasternal notch, and in 2.2%, the artery crossed the trachea more than 2 cm above this notch [16]. Among 336 tracheotomy cases, 4 patients (1.2%) had innominate arteries situated > 2 cm above the sternal notch, all of whom were at increased risk during tracheostomy.

Thus, an HRIA is typically defined as an IA whose superior margin crosses the anterior tracheal midline more than 2 cm above the suprasternal notch. Preoperative imaging modalities—such as Doppler ultrasound, CT/CTA, MRI/MRA, or angiography of the neck and upper thorax—can help detect these anomalies and reduce surgical risk [16].

Wannitta et al. reported a 72‐year‐old woman referred for tracheostomy, where preoperative imaging revealed an HRIA just above the suprasternal notch [1]. Given the high operative risk and poor prognosis due to metastatic pancreatic carcinoma, conservative management was selected. Akhtar et al. reported a 40‐year‐old woman in whom an HRIA was identified intraoperatively during thyroidectomy, coursing over the third and fourth tracheal rings. The surgical team took meticulous precautions to prevent vascular injury [2]. Dalati et al. reported two tracheostomy cases in which a pulsating mass was observed in the midline of the lower neck. In both cases, CT confirmed an HRIA. To prevent TIF, a cartilage flap was fashioned from the anterior tracheal wall and anchored to the skin, creating a protective barrier between the tracheostomy site and the vessel [3].

5.2. Preventive Measures for IA Hemorrhage Before and During Tracheotomy

5.2.1. Preoperative

Preventing intraoperative vascular complications begins with careful preoperative planning. Imaging studies—including ultrasound, CTA, contrast‐enhanced CT, MRI/MRA, or digital subtraction angiography (DSA)—should be thoroughly reviewed to assess the position and trajectory of the IA and common carotid arteries relative to the trachea. Visible pulsations in the suprasternal notch should raise suspicion of an HRIA.

In this case, two prior neck surgeries had significantly altered the patient's cervical anatomy, displacing the carotid arteries medially and closer to the trachea. This anatomical distortion substantially increased the risk of intraoperative bleeding and highlights the need for detailed preoperative imaging and planning. Sargunaraj et al. reported two cases of arterial injury during tracheal surgery due to anomalous vascular anatomy [14]. In one case, the IA bifurcated earlier and on the left side of the trachea; in the other, it followed a horizontal pretracheal course above the clavicle. These cases emphasize that assessment of peritracheal vascular anatomy is as critical as airway evaluation. Nijkamp et al. described an aberrant IA discovered during total laryngectomy, which significantly complicated surgical dissection and tracheostoma creation [17]. They concluded that angiography should be considered when vascular anomalies are suspected.

5.2.2. Intraoperative

Avoidance of low tracheotomies is essential. Most researchers recommend not incising below the fourth tracheal ring. In this patient, the previous incisions were positioned < 2 cm above the sternal notch, and due to the short neck and distorted anatomy, dissection extended too far inferiorly. Ideally, the incision should have been placed 2 cm or more above the sternal notch. When reopening previous scars, dissection should proceed in a cranial rather than caudal direction to reduce the risk of HRIA injury.

Dense fibrotic tissue from prior surgeries obscured anatomical planes and landmarks, making palpation of the trachea challenging. The tracheal wall was also softened and difficult to identify. In such cases, careful digital palpation of the thyroid cartilage and tracing downward to the cricoid cartilage and tracheal rings can assist in localizing the airway. Needle aspiration with saline to detect air bubbles may also help confirm tracheal entry.

If an HRIA is encountered during tracheostomy, a protective technique such as an inverted Björk flap can be employed. First described by Björk and Engström and later formalized by Kinley, this U‐shaped tracheal flap can facilitate safe tube exchange and reduce the risk of TIF [18]. Netzer et al. reported seven HRIA cases in which the flap was used successfully, with no postoperative bleeding observed during 9–46 months of follow‐up [19]. Nijkamp et al. also utilized a pectoralis major muscle flap to shield the aberrant vessel from the tracheostomy site [17].

5.3. Emergency Management of IA Injury During Tracheotomy Under Local Anesthesia

When sudden and massive bleeding occurs during tracheotomy, IA injury must be considered. Immediate hemorrhage control should be attempted using moderate digital or gauze pressure, avoiding excessive force that could compromise cerebral blood flow.

Because the patient is conscious under local anesthesia, panic and agitation from pain or blood loss can interfere with surgical progress. Verbal reassurance is vital. Rapid completion of the tracheotomy is necessary to secure the airway. If anatomical distortion prevents identification of the trachea, the thyroid cartilage and cricoid cartilage can be used as reliable landmarks. Needle aspiration can confirm tracheal entry, and the surrounding vessels should be carefully palpated to avoid further injury.

5.4. Management of IA Injury

5.4.1. Surgical Repair

5.4.1.1. Median Sternotomy, Suturing or Ligation

Open surgical repair options include median sternotomy, direct vascular suturing, ligation, or interposition grafting. Sargunaraj et al. described successful suture repair of a common carotid artery tear at the IA bifurcation [14]. In contrast, TIF typically requires more extensive repair via sternotomy due to the complex location of the fistula. Kondajji et al. reported sternotomy with ligation of the IA in a patient with TIF, emphasizing the importance of rapid recognition and surgical intervention [20]. Noguchi et al. performed sternotomy and arterial clamping for TIF in a child without removing the existing tracheostomy tube [21]. Kaneko et al. demonstrated that suprasternal collar incisions can offer a less invasive alternative to sternotomy in selected cases [22]. In certain situations, resection of the right clavicular head can improve exposure. If collateral cerebral perfusion is sufficient, ligation of the innominate, carotid, or subclavian arteries can be performed safely, as shown by Okada et al. [10].

5.4.1.2. Venous Graft Reconstruction

When direct suture repair is not feasible due to an irregular laceration, venous grafts may be used for vascular reconstruction. Sargunaraj et al. described repair with a left internal jugular vein graft, reinforced with strap muscle [14]. Dahill et al. reported successful use of a saphenous vein graft to repair a carotid artery defect caused by a delayed tracheo‐carotid fistula [23].

5.4.2. Endovascular Repair

Endovascular management is a promising alternative to open surgery, particularly in high‐risk patients. Covered stent placement via brachial artery access can control bleeding and preserve cerebral blood flow. Laswi et al. reported successful endovascular repair of TIF in a patient with prior sternotomy and high surgical risk [24]. Chien et al. used a combination of extracorporeal membrane oxygenation (ECMO), endovascular stenting, and surgical bypass to rescue a child with ruptured TIF [25]. Other successful cases of stent graft repair have been reported by Joseph et al. [26], Kakimoto et al. [27], and O'Malley et al. [28], with favorable outcomes and lower complication rates compared to open repair. Taechariyakul et al. performed a pooled cohort analysis showing that endovascular repair offers comparable survival rates and lower complication risks than open surgery for TIF [29].

5.5. The Role of MDT in the Management of IA Injury

MDT coordination is critical in managing complex vascular injuries during airway procedures. Collaboration between otorhinolaryngology surgeons, vascular surgeons, cardiothoracic surgeons, anesthesiologists, radiologists, and critical care teams enables rapid diagnosis, hemodynamic stabilization, and definitive treatment. In the presented case, activation of the MDT allowed a seamless transition from local airway control to hybrid OR‐based angiography and stenting. Cardiothoracic surgeons can provide open surgical solutions including sternotomy, ligation, or graft repair. However, given the risks associated with open procedures—particularly in patients with prior surgeries—endovascular approaches are increasingly favored. Chien et al. highlighted the value of combining ECMO, endovascular stenting, and surgical bypass in managing life‐threatening TIF, reinforcing the life‐saving potential of MDT‐driven care [25].

5.6. Limitations

This scoping review is limited by the small number of reported cases and the inherent constraints of case‐based evidence. Differences in reporting quality, surgical techniques, and follow‐up make comparisons difficult, and publication bias may favor dramatic or survivable cases. Therefore, while the findings offer useful clinical insights, their generalizability is limited and should be interpreted with caution.

6. Conclusion

In conclusion, this case highlights the importance of thorough preoperative assessment, especially in patients with prior neck surgeries. Identifying vascular anomalies such as an HRIA via imaging is essential to prevent fatal complications. Intraoperative strategies such as proper incision planning, cautious dissection, and the use of protective flaps can minimize risk. In the event of massive hemorrhage, rapid bleeding control, airway management, and activation of the MDT are critical. Among treatment options—including sternotomy, graft repair, and ligation—endovascular stenting offers a fast, minimally invasive, and effective solution. MDT collaboration remains the cornerstone of successful outcomes in complex vascular emergencies during tracheotomy. This case further highlights the critical role of MDT collaboration in managing vascular emergencies during airway surgery and illustrates the unique surgical challenge posed by the combination of a high‐riding IA and extensive prior thyroid cancer surgery.

Funding

This study was funded by the Key Research and Development Program of Zhejiang Province (2023C03066) and the medical and health research project of Zhejiang province (2023RC009).

Ethics Statement

This study was approved by the Institutional Review Board of the First Affiliated Hospital, Zhejiang University School of Medicine.

Consent

Written informed consent was obtained from the patient for participation and for publication of this case report and accompanying clinical information and images.

Conflicts of Interest

The authors declare no conflicts of interest.

Zhong J.‐T., Yu C.‐H., Chen Z., Bao Y.‐Y., and Zhou S.‐H., “Multidisciplinary Team‐Assisted Rescue of Innominate Artery Hemorrhage During Tracheotomy for Bilateral Vocal Cord Paralysis Post‐Thyroidectomy for Thyroid Cancer: A Case Report and Scoping Literature Review,” Laryngoscope Investigative Otolaryngology 11, no. 1 (2026): e70356, 10.1002/lio2.70356.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.