ACA App
Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 770 Small font size Default font size Increase font size Print this article Email this article Bookmark this page
 


 

 
     
    Advanced search
 

 
 
     
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case report
   Discussion
   Summary
    References
    Article Figures

 Article Access Statistics
    Viewed1021    
    Printed11    
    Emailed0    
    PDF Downloaded89    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents
CASE REPORT  
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 568-571
Vascular airway compression management in a case of aortic arch and descending thoracic aortic aneurysm


Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Click here for correspondence address and email

Date of Submission08-Mar-2016
Date of Acceptance19-May-2016
Date of Web Publication6-Jul-2016
 

   Abstract 

Airway compression due to distal aortic arch and descending aortic aneurysm repair has been documented. This case of tracheal and left main stem bronchus compression due to aortic aneurysm occurred in a 42-year-old man. The airway compression poses a challenge for the anesthesiologist in airway management during aortic aneurysm repair surgery. The fiber-optic bronchoscope is very helpful in decision-making both preoperatively and postoperatively in such cases. We report a case of airway compression in a 42-year-old patient who underwent elective distal aortic arch and descending aortic aneurysm repair.

Keywords: Airway compression; Aortic aneurysm; Fiber-optic bronchoscopy; Tracheomalacia

How to cite this article:
Kumar A, Dutta V, Negi S, Puri G D. Vascular airway compression management in a case of aortic arch and descending thoracic aortic aneurysm. Ann Card Anaesth 2016;19:568-71

How to cite this URL:
Kumar A, Dutta V, Negi S, Puri G D. Vascular airway compression management in a case of aortic arch and descending thoracic aortic aneurysm. Ann Card Anaesth [serial online] 2016 [cited 2019 Nov 15];19:568-71. Available from: http://www.annals.in/text.asp?2016/19/3/568/185568



   Introduction Top


Vascular tracheobronchial compression syndrome could be acquired or congenital, commonly seen with double aortic arch, aberrant subclavian artery, and pulmonary artery sling. [1] Kommerell's diverticulum is a rare cause of tracheobronchial compression. [2] Aneurysms of aortic arch and descending thoracic aorta can also cause airway compression. [3] Chronic compression of trachea can lead to tracheomalacia. [4] Various methods are used to rule out airway compression or tracheomalacia in the postoperative period. [1] We describe a case where intraoperative fiber-optic bronchoscopy (FOB) was used to rule out the airway compression.


   Case report Top


A 42-year-old male was admitted in our cardiac center with a history of dry cough, hoarseness of voice, and chest pain for the past 4 months. Chest X-ray showed a widened mediastinum and dilated descending thoracic aorta with elevated left hemidiaphragm [Figure 1]. Computed tomography (CT) angiography revealed a large fusiform aneurysm of the arch of aorta and proximal descending thoracic aorta, distal to the left common carotid artery with involvement of origin of the left subclavian artery. The descending thoracic aorta showed aneurysmal dilatation till D8 level. The saccular part of the aneurysm measured 8.5 cm × 7.0 cm with total craniocaudal span of the aneurysmally dilated segment measuring 16 cm. Compression and narrowing of the trachea was seen with displacement of the trachea and esophagus toward the right. The left major bronchus was mildly displaced anteriorly. Atelectatic changes were seen in the left lower lobe [Figure 2].
Figure 1: Posteroanterior view of chest X-ray depicting aortic arch aneurysm and elevated left diaphragm

Click here to view
Figure 2: (a) Contrast-enhanced computed tomography chest showing aortic arch aneurysm compressing the tracheal lumen and left main stem bronchus. (b) Three-dimensional reconstructed view of the aneurysm

Click here to view


The surgical plan in this case was to exclude the thoracic aneurysm and reduce the volume of the aneurysm to reduce compression on the airways. This aneurysm could have been treated by placing a stent graft, but this would not have reduced pressure on the airways for several weeks to months. Thus, the open surgical repair was planned under cardiopulmonary bypass (CPB) through peripheral cannulation. [5] Transesophageal echocardiography was performed perioperatively in this case.

In preanesthetic assessment, all laboratory investigations were normal, with arterial pressure (blood pressure [BP]) of 110/70 mmHg and heart rate of 72 beats/min. Preinduction monitoring included electrocardiogram, pulse oximetry, bispectral index, and invasive BP in the right radial and left femoral artery. Femoral vein and femoral artery were prepared for emergency femoro-femoral bypass. After induction of anesthesia and endotracheal intubation, FOB was performed to see the extent of tracheal compression. It showed a narrowed and pulsatile trachea at the level of carina. The left main stem bronchus was also narrowed. The right main stem bronchus was normal in caliber [Figure 3].
Figure 3: Preoperative fiber-optic bronchoscopic image showing external compression of the trachea (white arrow) (a) and left main stem bronchus (black arrow) (b) by aortic arch aneurysm

Click here to view


After heparinization, CPB was commenced using the right femoral and right axillary arterial cannulation. Interposition dacron graft of 16 mm was used for anastomosis of thoracic aorta. The left subclavian artery was sacrificed. Before chest closure, a repeat FOB was carried out to see the residual tracheal compression and rule out the presence of tracheomalacia. Bronchoscopy showed a normal caliber trachea at the level of carina [Figure 4]. The left main stem bronchus was also normal in caliber. No residual narrowing or tracheomalacia was seen. The patient developed quadriplegia in the postoperative period, which was successfully managed with cerebrospinal fluid drainage. The patient was extubated on postoperative day 6. Postextubation, the patient was stable with no difficulty in breathing and no stridor. On the 10 th postoperative day, the patient was discharged from the hospital.
Figure 4: Postoperative fiber-optic bronchoscopic image showing trachea, carina, and both main bronchus with no narrowing of tracheal lumen or left main bronchus

Click here to view



   Discussion Top


Tracheobronchial compression is a well-known complication of aneurysms of the ascending aorta and/or the aortic arch. [4] In general, compression occurs because of the close anatomic relationship of the aortic arch to the trachea and the left main stem bronchus. Patients with thoracic aortic aneurysm (TAA) may be asymptomatic or may be found incidentally during workup for other processes. Symptoms vary according to the size, location, and changes in the aneurysm. Tracheobronchial compression commonly presents with chest, back, and abdominal pain in patients who are symptomatic. Hoarseness may signify vagus or left recurrent laryngeal nerve compression. Wheezing, dyspnea, or cough suggest tracheal compression. Hemoptysis may be a sign of aneurysmal erosion into the trachea. The findings of the physical examination are usually normal. CT scanning, magnetic resonance imaging, angiography, and transesophageal echocardiography are most often used to assess thoracic aneurysm. The preferred method of assessment depends on the stability of the patient, the availability of radiographic modalities, and the preference of the surgeon. However, CT scanning is most commonly used in both emergent and outpatient settings to diagnose and follow thoracic aneurysm. Chest radiography should be obtained in the initial workup of patients with chest discomfort. Findings suggestive of aneurysm include mediastinal widening, blurring of the aortic knob, and tracheal displacement. An elevated hemidiaphragm may suggest phrenic nerve compression from mass effect, as seen in our case, but this finding is exceedingly rare compared with the other findings listed. Intravenous contrast-enhanced CT scanning is the investigation of choice for the diagnosis. Its sensitivity is 96-100% and specificity is 99% for detecting aneurysms. CT scanning is useful in evaluating aneurysm size, proximal and distal extension, presence or absence of dissection, and in seeking other pathologies within the chest. Contrast angiography is useful in assessing the complex aortic pathology and identifying the anatomy of branch vessels. Its sensitivity is 85% and specificity is 95% in detecting aneurysms. [5] Angiography has been considered the gold standard for specifically delineating topographic vascular anatomy, relative dimensions, and flow distributions, which can explain the mechanism of airway compression in many such cases. [5],[6] Magnetic resonance angiography is useful in assessing the aortic anatomy, the size of the aneurysm, the dissection, and the branch vessels. Its sensitivity is 100% and specificity is 100% in detecting aneurysms. Magnetic resonance angiography does not require the administration of iodinated radiologic contrast material.

Patients who present with a descending TAA and require lung isolation can be managed with either a left-sided double-lumen endotracheal tube (DLT) or a right-sided DLT if there is a compression of the entrance of the left main stem bronchus. [7] With a large aneurysm of the descending thoracic aorta, the anatomy can be distorted if the aneurysm compresses the trachea or the entrance of the left main stem bronchus. [8],[9] This may make the placement of a left-sided DLT dangerous in patients in whom the aneurysm involves the left main stem bronchus because the potential exists for rupture of the aneurysm. Contraindications for the use of double-lumen tubes include anatomic barriers that make positioning improbable or dangerous (i.e., carinal or bronchial lesions, strictures, and vascular compression by aortic aneurysm). [10] Therefore, a decision of using single-lumen tube was taken. The crucial importance of intraoperative bronchoscopic monitoring of airway decompression and its effectiveness has been emphasized in several reports. [11],[12],[13] Flexible bronchoscope facilitated inspection of all the accessible airway portions, assessment of endoluminal tissue properties of the airway wall, and effective direct clearing of retained secretions after decompression.

Tracheomalacia can be sometimes associated with congenital (or acquired) aortic arch abnormalities. The acquired form of tracheomalacia may be secondary to chronic external compression by mediastinal mass, but rarely, chronic aortic arch aneurysm causing tracheomalacia has been reported in literature. [4] As such in this case, the history was of 4 months only and any aneurysm causing tracheomalacia is rare.

Tracheomalacia can occur in cases of aortic arch aneurysm with a posterior expansion, a long-standing compression of the tracheobronchial tree, and can be managed with the endoscopic implantation of a silicon T or T-Y tube. FOB is used to diagnose the airway compression and it is also being used to deploy expandable metallic airway stents. [14],[15]

Our patient did not have airway compression postsurgery and therefore, he was planned for early weaning and extubation. This case report highlights the utility of confirming the extent, location, and severity of tracheal and bronchial compression with an FOB before and after the aortic arch aneurysm surgery, which helps in deciding the course of action for airway management.


   Summary Top


Patients with a large TAA may develop an airway compression. During the preoperative evaluation, review of the chest X-ray and CT scan is important to determine if the trachea or the left main stem bronchus has any compression due to a large aneurysm. In addition, review of the chest CT scan will determine the precise location of the compression. FOB is the best method to diagnose an airway compression in patients with a descending TAA to rule out any postoperative tracheomalacia and deciding the course of action postoperatively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Sebening C, Jakob H, Tochtermann U, Lange R, Vahl CF, Bodegom P, et al. Vascular tracheobronchial compression syndromes - Experience in surgical treatment and literature review. Thorac Cardiovasc Surg 2000;48:164-74.  Back to cited text no. 1
    
2.
Herway ST, Benumof JL, Golts E, Manecke GR. Major positional obstruction of the trachea in a patient with a right-sided aortic arch and Kommerell's diverticulum. J Cardiothorac Vasc Anesth 2015;29:146-8.  Back to cited text no. 2
    
3.
Koomen E, Schurink GW, Mochtar B, Jacobs MJ, Smets RJ. Repair of thoracic aortic aneurysm associated with tracheal and right mainstem bronchus compression. J Cardiothorac Vasc Anesth 2007;21:88-90.  Back to cited text no. 3
    
4.
Maddans M, Pearson FG. Tracheomalacia. In: Pearson FG, editor. Thoracic Surgery. New York: Churchill Livingstone; 2002. p. 272-6.  Back to cited text no. 4
    
5.
von Segesser LK. Peripheral cannulation for cardiopulmonary bypass. Multimed Man Cardiothorac Surg 2006: mmcts.2005.001610. doi:10.1510/mmcts.2005.001610.  Back to cited text no. 5
    
6.
Kumeda H, Tomita Y, Morita S, Yasui H. Compression of trachea and left main bronchus by arch aneurysm. Ann Thorac Surg 2005;79:1038-40.  Back to cited text no. 6
    
7.
Campos J. Lung isolation. In: Slinger P, editor. Principles and Practice of Anesthesia for Thoracic Surgery. Ch. 16. New York, NY: Springer Publisher; 2011. p. 227-46.  Back to cited text no. 7
    
8.
Campos JH, Ajax TJ, Knutson RM, Moyers JR, Rossi NP, Kuretu ML, et al. Case conference 5 - 1990. A 76-year-old man undergoing an emergency descending thoracic aortic aneurism repair has multiple intraoperative and postoperative complications. J Cardiothorac Anesth 1990;4:631-45.  Back to cited text no. 8
    
9.
Varkey B, Tristani FE. Compression of pulmonary artery and bronchus by descending thoracic aortic aneurysm. Perfusion and ventilation changes after aneurysmectomy. Am J Cardiol 1974;34:610-4.  Back to cited text no. 9
[PUBMED]    
10.
Campos J. Lung isolation in patients with difficult airways. In: Slinger P, editor. Principles and Practice of Anesthesia for Thoracic Surgery. Ch. 17. New York, NY: Springer Publisher; 2011. p. 247-58.  Back to cited text no. 10
    
11.
Binet JP, Longlois J. Aortic arch anomalies in children and infants. J Thorac Cardiovasc Surg 1977;73:248-52.  Back to cited text no. 11
[PUBMED]    
12.
Lincoln JC, Deverall PB, Stark J, Aberdeen E, Waterston DJ. Vascular anomalies compressing the oesophagus and trachea. Thorax 1969;24:295-306.  Back to cited text no. 12
[PUBMED]    
13.
Louhimo I, Leijala M. The treatment of low retrosternal tracheal stenosis in the neonate and small children. Thorac Cardiovasc Surg 1985;33:98-102.  Back to cited text no. 13
[PUBMED]    
14.
Reed AB, Reed MF. Endobronchial and endovascular management of bronchial compression by a thoracic aortic aneurysm. Ann Thorac Surg 2012;94:273-4.  Back to cited text no. 14
    
15.
Gelsomino S, Romagnoli S, Dragotto A, Cassai M, Fiorani B, Sorbara C, et al. Multistep endobronchial-endovascular approach in recurrent acute respiratory failure caused by thoracic aneurysm. J Thorac Cardiovasc Surg 2005;129:1436-8.  Back to cited text no. 15
    

Top
Correspondence Address:
Alok Kumar
Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.185568

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top