Objectives: To review the clinical presentation, predisposing factors, prevention strategies, management, and outcomes of innominate artery hemorrhage following tracheostomy. Study Design and Setting: We report the case of an 80-y-old patient who experienced sudden massive innominate artery hemorrhage 11 days post tracheostomy. We review the literature and present recommendations for management and prevention. Results: Emergency median sternotomy with ligation and resection of the affected segment was performed with no neurological or vascular sequelae. Conclusions and Significance: The risk of innominate artery hemorrhage may be minimized with simple measures. Management by ligation and resection of the pathological segment of artery has superior outcomes to primary vascular reconstruction with maintenance of blood flow. Bypass procedures are not routinely required and have not been shown to confer any significant benefit. Resection without reconstruction is associated with a surprisingly low incidence of neurological sequelae.