Too Big to Fail? -- An Aggressive Strategy For a Dire Problem

Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aorto-tracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery the authors propose a surgical treatment, that is reproduceable for the correct anatomic configuration - an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage to prevent infection. While this intervention seems a large undertaking for a small defect, it is a safe and durable repair.