Year : 2012  |  Volume : 15  |  Issue : 3  |  Page : 233--235

Compression of undiagnosed aberrant right subclavian artery during transesophageal echocardiography probe insertion


Vishal Garg1, Reena Joshi2, Raja Joshi2,  
1 Department of Cardiac Anaesthesia, Sir Ganga Ram Hospital, Rajinder Nagar, Delhi, India
2 Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, Delhi, India

Correspondence Address:
Vishal Garg
Department of Cardiac Anaesthesia, Sir Ganga Ram Hospital, Rajinder Nagar, Delhi - 110 060
India

Abstract

Transesophageal echocardiography (TEE) has become an important monitoring tool for the anesthesiologist during repair of intracardiac defects. Although the incidence of reported complications associated with its use is low, one should be careful during the insertion and use of TEE probe, as it may result in potential devastating problems. We present a case of undiagnosed aberrant right subclavian artery (ARSA) that got compressed by the TEE probe during its insertion. It was noticed because of the presence of the right radial artery catheter, else it would have passed unnoticed.



How to cite this article:
Garg V, Joshi R, Joshi R. Compression of undiagnosed aberrant right subclavian artery during transesophageal echocardiography probe insertion.Ann Card Anaesth 2012;15:233-235


How to cite this URL:
Garg V, Joshi R, Joshi R. Compression of undiagnosed aberrant right subclavian artery during transesophageal echocardiography probe insertion. Ann Card Anaesth [serial online] 2012 [cited 2019 Dec 9 ];15:233-235
Available from: http://www.annals.in/text.asp?2012/15/3/233/97980


Full Text

 Introduction



Transesophageal echocardiography (TEE) is routinely practised for perioperative evaluation of congenital cardiac defects. The complications reported with the use of TEE in infants and the pediatric population is low. [1] The following case report describes compression of a previously undiagnosed aberrant right subclavian artery (ARSA) during insertion of the TEE probe.

 Case Report



An 8-month-old, 6-kg female baby was admitted with history of recurrent respiratory tract infections and presented in congestive heart failure. Preoperative transthoracic echocardiogram revealed a large inlet muscular VSD, severe tricuspid regurgitation and patent ductus arteriosus. After medical stabilisation with decongestive measures, the child was scheduled for surgical repair of VSD.

The child was premedicated with intramuscular ketamine. The monitoring, included 5-lead electrocardiogram, a blood pressure cuff on the left leg and two pulse oximeters, one on the left hand and other on the right leg. Anesthetic induction with sevoflurane, fentanyl and neuromuscular blockade with pancuronium bromide was uneventful. The trachea was intubated with a 4.5-mm ID uncuffed endotracheal tube. The right radial artery was percutaneously cannulated with a 22G catheter for arterial pressure monitoring and a 4-Fr triple-lumen central venous pressure catheter was inserted in the right internal jugular vein.

A TEE probe 3-7 MHz, 9 mm diameter omniplane (S7-3t Explora, Philips HD11 XE system, Philips Healthcare, 3000 Minuteman Road, Andover, Massachusetts, USA) was inserted after positioning the patient for surgery. After inserting the probe up to the depth of 15 cm from the incisors, sudden dampening of the arterial pressure waveform was noticed [Figure 1]. There was no change in the other parameters. The TEE probe was advanced further into the esophagus but the arterial pressure waveform continued to be dampened. The TEE probe was then removed, immediately the arterial trace was restored [Figure 2]. We inserted the TEE probe a second time and noticed the same phenomenon. Probability of an ARSA was entertained and we decided against insertion of TEE probe for the procedure. Surgical procedure was uneventful and the child did well in the postoperative period and was discharged on postoperative Day 7. A computed tomography (CT) angiography was performed on the first follow-up visit, which confirmed the diagnosis of an ARSA originating from the descending thoracic aorta traversing behind the esophagus into the right axilla. [Figure 3] shows the CT angiogram at T2-T3 level in transverse section depicting the origin of the ARSA from the descending aorta and its course behind the esophagus. [Figure 4] is a coronal section view of the CT angiogram showing the origin of ARSA. Importantly, there was no diverticulum of kommerell.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Discussion



The development of a pediatric probe has enabled the use of TEE in infants as small as 3 kg. Use of TEE is considered a noninvasive procedure, but one should be aware of the problems that may arise because of its use, especially in the pediatric population. There have been reports of compression of normal mediastinal structures [2],[3] as well as the anomalous ones. [4],[5] Compression of the ARSA by TEE probe is an underreported complication in the literature.

An ARSA is reported in about 38% of the children with Down's syndrome and congenital heart disease. [6],[7] Most of these patients are asymptomatic, and the anomaly is detected incidentally or later in life as dysphagia. Rarely, in the presence of a kommerell diverticulum at the base of ARSA origin, they may present earlier with varying degree of stridor. In the index case, the child was asymptomatic, although noisy and effortful breathing in young infants with congestive heart failure is difficult to differentiate. The incidental diagnosis in our patient was possible only because of the presence of right radial artery catheter, else we could have potentially ended up with prolonged compression of the ARSA which might have resulted in thrombosis or subsequent ischemia of the right arm.

In presence of ARSA, the compression of the descending aorta also would have clinically manifested similarly; however, since there was no change in the pulse oximetry wave-form placed in the lower limb it was unlikely that the loss of radial arterial waveform was because of compression of descending thoracic aorta. The dampening of right radial arterial trace because of the compression of the descending aorta is much more ominous problem and could result in over-treatment of falsely low arterial pressure and consequent cerebral hyperperfusion and postoperative renal or liver dysfunction as well as paraplegia.

With the ever increasing use of TEE in intracardiac repairs of congenital cardiac defects, it is quite likely that we may encounter such problems more frequently. It would require the anesthesiologist or the echocardiographer to be more vigilant and aware of such a possible complication. It would be worthwhile to monitor the circulation of both the upper extremities and lower extremities while placing a TEE probe especially in small children. This can be achieved by placing a radial arterial catheter in one upper extremity and by pulse oximetry or manually checking the presence of arterial pulsations in other limb and lower limbs. Any dampening of the radial artery trace or pulse oximetry trace or loss of pulse may indicate compression of an anomalous vessel or compression of the descending aorta and thus prevent from a possible drastic complication. Use of micro-TEE probes, especially in smaller children, can also avoid such complications. Although intraoperative TEE is a relatively safe procedure, even in small children and infants, careful attention is required with respect to its insertion and manipulation.

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