A 28-year-old man with a tracheostomy had two episodes of hemorrhage from an arteriotracheal fistula secondary to erosion of the cannula tip into the right subclavian and the right common carotid arteries. Arteriotracheal fistual formation is associated with high pressure cuffs, low tracheostomies, excessively long or curved tracheostomy tubes, mediastinal infections, and superiorly placed anatomic variants of the innominate artery. Repeat fistula formation can be anticipated until the underlying factor is eradicated.