Tracheo-innominate artery fistula (TIF) is a rare but catastrophic and almost always fatal complication of tracheostomy. Two surgically intervened TIF cases are presented. In both cases, innominate artery ligation was performed. The first patient died due to respiratory failure 10 hours after operation. The second patient was discharged with normal neurologic examination on the 12th day of operation. Since the mechanism of injury leading to TIF is pressure necrosis, it is of vital importance to be aware of the predisposing factors and to take preventive measures. On the other hand, only patients treated with emergency surgery tend to survive.