Anesthetic management of right brachiocephalic artery aneurysm causing tracheal compression.

The airway compression poses a challenge for the anesthesiologist in airway management during aneurysm repair surgery.

INTRODUCTION

A 34-year-old male admitted in our institute with a history of hoarseness of voice since 15 days, pain over right shoulder since 4 days and difficulty in breathing since 3 days. Chest X Ray showed a well-defined radio-opacity in right paratracheal location, causing mass effect in the form of displacement of trachea to left side [Figure 1]. Computerized Tomography scan revealed pseudo aneurysm arising from junction of right common carotid artery and subclavian artery with peripheral thrombosis [Figure 2]. The surgical plan was to exclude the aneurysm and reduce the volume of aneurysm to reduce the compression on the trachea. The open surgical repair was planned under cardiopulmonary bypass (CPB).[12345]

Figure 1

A well-defined radio-opacity is seen in right paratracheal location, causing mass effect in the form of displacement of trachea to left side. The lesion is seen extending above the clavicle. Impression:-superior mediastinal mass with mass effect on trachea

Figure 2

CTA coronal image showing aneurysm arising from right brachiocephalic artery and compressing the tracheal lumen

Peripheral Bypass instituted under local anesthesia and patient was taken on CPB. Patient was induced and intubated and put on mechanical ventilation after institution of CPB. Bronchoscopy was done and Endotracheal Tube (ETT) was placed beyond tracheal compression and no tracheal rent was noted. Patient was weaned off CPB uneventfully. The patient was extubated on post-operative day 1 after TPiece Trial.

DISCUSSION

Patients with aneurysm of Aortic Arch and its branches pose a challenge for the anesthesiologist in airway management during aneurysm repair surgery. During induction of anesthesia there may occur collapse of airway after administration of induction drugs due to skeletal muscle relaxation. This may result in sudden and marked hypoxia if airway patency is not established promptly via endotracheal intubation. In case of severe tracheal compression, it may be very difficult to intubate and bypass tracheal compression via endotracheal tube. Therefore, a decision of awake peripheral cannulation and establishment of CPB was planned.[5] Tracheomalacia can be associated with congenital aortic arch abnormalities.[2] This case highlights the importance of formulating a plan for the anesthetic management of patients with aneurysm of aortic branch causing severe tracheal compression and preparedness for postoperative management.

Declaration of patient consent

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.