Managing the Unpredictable: Airway and Anesthetic Challenges in a Patient with an Expanding Recurrent Mycotic Pseudoaneurysm of the Right Brachiocephalic Artery- A case report and literature review.

doi:10.21203/rs.3.rs-3747933/v1

Background:

Airway obstruction requires urgent intervention. When dealing with right brachiocephalic artery mycotic pseudoaneurysms, the risk of rupture and massive hemorrhage adds greater urgency to the management. Furthermore, tracheal compression presents difficulties during airway management. This report highlights the airway and anesthetic challenges encountered during the procedure and emphasizes the importance of tailored intervention for optimal patient care.

Case presentation:

A 38-year-old male patient presented with a three-day history of right neck swelling and neck pain, status post open repair of right subclavian artery pseudoaneurysm eight months ago.

CT chest revealed a large right brachiocephalic artery pseudoaneurysm with partial thrombosis, associated tracheal compression and deviation. During initial work up, the cervical mass increased and the patient developed shortness of breath and hoarseness, necessitating urgent surgical intervention.

Initially planned awake fiber-optic intubation was not feasible due to his uncooperative state and progressive respiratory distress.

The femoral artery and vein was prepped in anticipation to promptly institute cardiopulmonary bypass in event of failed intubation and ventilation, or circulatory collapse.

After Intravenous induction, mask ventilation with an oral airway was adequate. Endotracheal intubation was performed using a C-MAC D-Blade Video-laryngoscopy and an armored tube over a stylet. Though the laryngeal view was edematous and displaced to the left side, careful neck manipulations enabled successful intubation without desaturation. A bronchoscopy confirmed proper tube placement beyond the tracheal compression. EZ blocker was inserted for potential lung isolation.

Despite the significant bleeding during the procedure, the surgical repair was successfully achieved.

Post-operative ICU stay was uneventful. Video-laryngoscopy showed edematous aryepiglottic folds and was treated with methylprednisolone. The patient was successfully extubated after 48 hours.

Conclusion

Overall, this case emphasizes the importance of early diagnosis, prompt surgical intervention, and effective teamwork in managing rare and potentially life-threatening conditions like mycotic pseudoaneurysms. It also highlights the critical role of anesthesiologists in providing optimal perioperative care, ensuring hemodynamic stability, managing airway challenges, and facilitating successful surgical outcomes.

Mycotic

Pseudoaneurysm

Brachiocephalic artery

Airway obstruction

Tracheal compression

Mycotic pseudoaneurysms of the brachiocephalic artery are rare but potentially life-threatening condition characterized by infected arterial dilatation. They typically result from bacterial or fungal dissemination to arterial walls. The term "mycotic" is derived from the resemblance of the aneurysms to mushrooms, rather than referring to their microbiological aetiology. Prompt surgical intervention is crucial to prevent rupture and associated complications^1–3. Herein, we describe the anesthetic approach to a patient requiring urgent surgical repair for a recurrent mycotic pseudoaneurysm of the right brachiocephalic artery causing tracheal compression and airway obstruction.

A 38-year-old male patient presented to the emergency department with a history of right neck swelling for three days associated with neck pain. He has a past surgical history of mini sternotomy and open repair of pseudoaneurysm of right subclavian artery eight months ago. Additionally, the patient has a medical history of poorly controlled hypertension. Initial work up showed WBC of 18.8x10³/uL, CRP 181 mg/L, ESR 70 mm/hr. CT chest revealed 51 x 31 mm enlarged pseudo-aneurysm arising from the right brachiocephalic artery associated with compression and displacement of the trachea (Fig. 1–2) Patient was started on empiric antibiotics (Piperacillin/Tazobactam and Vancomycin). PET CT scan was planned to rule out endovascular infection. However, the patient developed a rapidly expanding, pulsatile neck mass (Fig. 3) during the admission which was associated with compression symptoms and deemed high risk for impending respiratory failure. It was decided to take him to the operating theater for an urgent surgical intervention.

Given the urgency of the situation and due to the presence of a quickly growing, pulsatile neck mass and the inability of establishing a surgical airway, the decision was made to proceed with general anesthesia as the only viable option. Awake fiber optic intubation was not feasible in this case as the patient was uncooperative and in respiratory distress.

Anesthetic Technique:

American Society of Anesthesiologists (ASA) standard monitors were applied, followed by the insertion of left radial artery cannula under local anesthesia for continuous blood pressure monitoring. Cerebral oximetry was also used to assess cerebral perfusion.

The femoral artery and vein was prepped in anticipation to promptly institute cardiopulmonary bypass in event of failed intubation and ventilation, or circulatory collapse.

It was decided to proceed with intravenous induction of general anesthesia, to avoid the risk of coughing and/or laryngospasm associated with awake fiberoptic intubation.

General anesthesia was induced intravenously with 200 mcg of fentanyl, 2 mg of midazolam, 150 mg of propofol, and 100 mg of rocuronium after adequate preoxygenation. A mask ventilation trial with an oral airway was adequate, followed by successful endotracheal intubation using a C-MAC D-Blade videolaryngoscope and a reinforced armored tube (size 7.0mm ID) over a stylet to pass beyond the tracheal compression to facilitate the passing of tube beyond the tracheal compression. The laryngeal view was edematous and displaced to the left side, posing a challenge for intubation (Fig. 4). However, with careful neck manipulations, successful intubation was achieved without oxygen desaturation. Flexible bronchoscope was utilized to assess the trachea post-intubation. Anesthesia was then maintained by sevoflurane inhalation and remifentanil IV infusion.

After intubation, a femoral central line was placed for administering vasopressors and two 16G peripheral lines were inserted. Intraoperatively, FloTrac™ Edward's continuous cardiac output monitor tracked stroke volume variation, systemic vascular resistance, cardiac output, and cardiac index.

Intraoperative Course:

After the induction of anesthesia an angiogram of the right brachiocephalic artery was performed to assess the extent of the pseudoaneurysm. A destination sheath was inserted through the femoral artery and sheath with an inflatable balloon was positioned in the proximal part of the right brachiocephalic artery. This was done to provide control in case of bleeding or rupture during the subsequent surgical repair.

Following the angiogram and positioning of the sheath, the surgical team proceeded with sternotomy and open repair of the right brachiocephalic artery pseudoaneurysm.

During the dissection of the right common carotid artery, an unforeseen complication arose as a sudden rupture of the pseudoaneurysm occurred, resulting in bleeding. Despite the presence of the balloon in the proximal part of the right brachiocephalic artery, it was unable to control the bleeding effectively. Consequently, the balloon was removed, and the surgical team swiftly responded by applying manual pressure to achieve control over the bleeding site. Through this immediate intervention, hemostasis was successfully attained, ensuring the cessation of bleeding.

The heart-lung machine was kept standby; in case of an emergent need for circulatory support. However, the surgical team successfully managed the bleeding using manual control techniques without the need for cardiopulmonary bypass. Additionally, patient received fluids, blood products and noradrenaline infusion during the surgery. The complex surgery lasted approximately 6 hours, ensuring successful vascular reconstruction, hemostasis and placement of bypass graft.

Postoperative Management:

The patient was transferred to the Surgical Intensive Care Unit (SICU) after the surgery; kept intubated, sedated, and mechanically ventilated. Airway edema was detected on video laryngoscopy; methylprednisolone was administered to reduce the edema. Extubation was successfully performed approximately 48 hours after surgery. On the fifth operative day, with satisfactory recovery, the patient was discharged to the general ward.

Brachiocephalic artery or innominate artery aneurysm are relatively rare with an incidence of 2 to 5 percent of all aneurysms affecting the aortic arch vessels and less than 1 percent of peripheral artery aneurysms in general^1,2. The primary cause of innominate artery aneurysms is degenerative disease or atherosclerosis, which is responsible for over 50 percent of true innominate artery aneurysms. Other less common causes include syphilis, tuberculosis, Kawasaki disease, Takayasu arteritis, Behcet disease, connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome. Trauma can also lead to innominate artery aneurysms, although most cases in this category are pseudoaneurysms. Mycotic (infected) innominate aneurysms are rare but have been documented^3,4. The arteries frequently affected by mycotic pseudoaneurysms include the aorta, peripheral arteries, cerebral arteries, and visceral arteries. Approximately 13.3% of mycotic pseudoaneurysms arise from infection of pre-existing aneurysms, with bacterial organisms, including Gram-positive cocci (predominantly S. aureus), accounting for 55%, and Salmonella accounting for 30-40%.

Most brachiocephalic artery aneurysms are found incidentally, while about 25 percent of the cases present with symptoms. Symptoms can vary and include pain due to expansion or rupture, ischemic symptoms affecting the brain or upper extremities, brachial plexus compression, hoarseness, dyspnea due to tracheal compression, Horner syndrome, hemoptysis, and rare cases of hemodynamic collapse from aneurysm rupture occurring in approximately 10 percent of patients^2,5. Computed tomographic (CT) angiography is the preferred and reliable imaging modality for assessing innominate artery aneurysms. It offers precise information on aneurysm size, thrombus presence, and the anatomical relationship between the aneurysm and adjacent structures. Treatment is recommended for symptomatic innominate artery aneurysms, as well as those with thrombus, which poses a potential risk of thromboembolic stroke or limb-threatening ischemia. Although, open surgical repair is still considered the standard approach for treating brachiocephalic artery aneurysms, it is associated with notable morbidity and mortality. This is primarily due to the requirement of a median sternotomy and cardiopulmonary bypass. Mycotic pseudoaneurysm is a severe clinical condition that carries substantial morbidity and mortality risks. The recommended treatment approach involves a combination of antibiotic therapy and extensive surgical debridement of the infected tissue, along with vascular reconstruction as necessary.

Anesthesia/Airway challenges:

Tracheobronchial compression by the vascular anomaly poses great airway and anesthetic challenges. Acute airway obstruction is associated with increased risk of perioperative cardiorespiratory collapse^6,7. Compression typically arises due to the close anatomical proximity between the aortic arch vessels and the trachea, as well as the left main stem bronchus. Acute airway obstruction caused by the aneurysm of the brachiocephalic artery has been reported in the literature^8,9.

Various methods are available for managing airway with tracheal compression, including awake fiberoptic intubation above or below the narrowed area with patient spontaneously breathing; General anesthesia with endotracheal intubation; General anesthesia using patient’s natural airway or spontaneous ventilation; employing high-frequency ventilation; utilizing cardiopulmonary bypass; and inserting an endotracheal stent. Each approach carries its own set of advantages and disadvantages.

Awake fiberoptic intubation is widely recognized as a safe and effective method for managing difficult airways. However, in certain situations, it may be necessary to reconsider the initial plan and opt for an alternative airway securing technique. We considered the possibility of performing awake fibreoptic intubation with or without sedation to maintain the patient's spontaneous breathing. However, our patient was uncooperative due to respiratory distress. Also, we recognized the potential complications arising from inadequate topicalization and an uncooperative patient, which could result in loss of vision during the procedure, coughing and/or laryngospasm. Such complications could increase the transmural pressure of the pseudoaneurysm and potentially lead to life-threatening rupture or further compression of the trachea.

Flexible bronchoscope facilitates the assessment of airway portions, airway wall properties including the endoluminal compression by the aneurysm and effective clearing of secretions. Numerous reports highlight the importance of intraoperative bronchoscopic monitoring of airway decompression and its effectiveness in these cases^8–10. Therefore, we decided to choose reinforced tube (Size 7.0 mm) with a soft tip to reduce the likelihood of tracheal or aneurysm rupture and assessed the airway with Flexible bronchoscope post-intubation.

Choice of airway equipment should be wisely instituted especially in patients with large aneurysm requiring lung isolation. Double lumen tube should be avoided due to anticipated difficulty in placement and also the potential risk for rupture of aneurysm. However, bronchial blockers can be utilized for lung isolation if necessary. In our case, lung isolation was not required.

It is imperative to prepare alternative options in case that endotracheal intubation fails to maintain oxygenation and ventilatory demands. Therefore, before inducing anesthesia, percutaneous cardiopulmonary support should be readily available^9,11,12. In our patient, femoral artery and vein was prepped in anticipation to promptly institute cardiopulmonary bypass in event of failed intubation and ventilation, or circulatory collapse.

Effective blood pressure management is crucial in tracheobronchial-vascular compression syndrome. Hypertension not only increases the risk of aneurysm rupture but also elevates the pressure exerted by the aneurysm on the trachea. Therefore, enhances the likelihood of further airway obstruction. An uncontrolled hypertension in our patient might have contributed to the rapid and progressive expansion of the pseudoaneurysm. The control of the blood pressure immediately was of paramount importance, which we did by using Labetalol pre-operatively.

Tracheomalacia can occasionally be linked to congenital or acquired abnormalities of the aortic arch. The acquired form of tracheomalacia is usually a result of prolonged external compression from a mediastinal mass. However, there have been rare cases reported in the literature where tracheomalacia was caused by a chronic aortic arch aneurysm¹³. Fiberoptic bronchoscope is useful tool to diagnose the tracheomalacia and also expandable metallic stent can be deployed.

This case is characterized by several challenges, including a difficult airway due to neck mass compression and airway edema, as well as an intraoperative rupture of the pseudoaneurysm (Table 1). However, with meticulous planning, proper monitoring, and prompt interventions, these challenges were successfully overcome, ensuring the patient's safety and optimal surgical outcomes.

Table 1. Summary of anesthetic concerns in mycotic pseudoaneurysm of brachiocephalic artery

This case report contributes to the existing literature (Table. 2) by documenting the airway and anesthetic management; and surgical techniques employed in the repair of a brachiocephalic artery mycotic pseudoaneurysm. Sharing such experiences helps enhance our understanding of these complex cases and guides future clinical decision-making for similar presentations.

Table 2. Review of case reports on airway management in aneurysms

Authors and Publication year	Patient’s Age and Gender	Diagnosis CT findings	Airway or tracheal compression	Anesthesia or Airway management	Surgical intervention	Outcome
Nishiwaki, Kimitoshi, et al. (1990)¹⁴	55 years old, male	Aneurysm of the ascending aorta	Compression from anterior tracheal wall from 2.5cm to the vocal cords to 8.5cm below	GA with armored ETT size 6mm, followed by bronchosopic guided tube advancement beyond stenosis with induced hypotension	Open repair of aneurysm	Uneventful recovery
Gorman, Randolph B., et al. (Dec 1993)¹⁵	77 years old, Male	Dissecting thoracoabdominal aneurysm	No compression	GA induction followed by single lumen ETT 8.5mm, left lung isolation with fogarty catheter, Post intubation bronchoscopy revealed lower one-third trachea 50% narrowed and right mainstem bronchus completely occluded	Open left thoracotomy while on CPB	Extended postoperative course
Koomen, Erik, et al. (Feb 2007)¹⁶	70 years old, Male	Aneurysmal dilation of the middle part of the descending thoracic aorta	Compression of the trachea and right main bronchus	General anesthesia with single lumen ETT size 9.0 mm with IPPV, supplemented by HFJV and left atriofemoral bypass for surgical access	Left thoracotomy and open repair of aneurysm	Weaned off from the mechanical ventilator on post op day 2
Jung, Hyun Ju, et al. (Dec 2009)¹¹	50 years old, Male	Aneurysm of the innominate artery with a large thrombus from rupture of the medial wall of the proximal innominate artery	Compression of Trachea	Emergency intubation with midazolam (5mg iv), followed by anesthetic induction with muscle relaxation in the OR	Open repair while on CPB	Uneventful recovery
Constenla, Iván, et al. (Sep 2012)¹⁷	63 years old, Male	Aneurysm of the innominate artery (IA) (brachiocephalic trunk) with a maximum diameter of 4.5 cm	Tracheal compression	General anesthesia, and fiberoptic bronchoscopy was used to achieve orotracheal intubation	Bypass from the ascending aorta to both common carotid arteries using a Dacron graft	Immediately Extubated postoperative
Mundada, Surbhi D. et al. (April-June 2016)¹⁸	36 years old, Female	Pseudoaneurysm arising from the right lateral wall of ascending aorta	No compression on trachea	GA induction with 7.5mm cuff tube under DL, followed by Femoral V-A CPB	Open repair on CPB	Extubated on POD 1
Kumar, Alok, et al. (Jul-Sep 2016)¹⁰	42 years old, Male	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	Compression and narrowing of the trachea was seen with displacement of the trachea and esophagus toward the right, mild compression of left main bronchus	GA induction with ETT intubation, followed by FOB to show the level of compression	Open repair on CPB	Extubated on POD 6
Dunn, Sarah A., et al. (Jan 2019)¹²	Not reported	Pseudoaneurysm of ascending aorta caused by mycotic infection of the aortic graft at the area of anastomosis from a type A dissection repair 3 years before.	Tracheal deviation and compression of both mainstem bronchus	Awake femoral V-A CPB followed by GA induction and intubation	Open repair	Not reported
Arora, Varun, et al. (Dec 2021)¹⁹	34 years old, Male	Pseudo aneurysm arising from junction of right common carotid artery and subclavian artery	Tracheal compression	Awake femoral V-A CPB, followed by GA induction and intubation. FOB to guide the tube beyond compression point.	Open repair	Extubated on POD 1
Das, Devishree, et al. (Jan 2022)²⁰	45 years old, Female	Pseudoaneurysm of right common carotid artery	Localized mass effect on the thyroid, larynx, trachea, and esophagus with a shift towards the left was detected	Emergency airway due to ruptured aneurysm: GA with ETT intubation, followed by Immediate Femoral V-A CPB	Open repair with Gortex graft	Extubated on 2^nd POD
Suda, Yasuhiro, et al. (Dec 2022)²¹	83 years old , female	Impending rupture of the ascending TAA and esophageal stenosis with significant amounts of food residues in the upper thoracic esophagus	TAA compressed the pulmonary artery and left bronchi	Awake endotracheal intubation was performed using a McGrath MAC® video laryngoscope with light sedation, followed by GA	Open repair of TAA	Extubated on POD 4
Montane-Muntane, Mar, et al. (Jan 2023)²²	16 years old , Male	Ascending aortic aneurysm (94 mm × 78 mm) that extended along 10 cm starting at 25 mm from the aortic ring	Extrinsic compression of the distal trachea	Step 1: GA induction, ETT intubation (7.5mm) with direct laryngoscopy (failed ventilation) Step 2: LMA insertion followed by fiberoptic intubation (7.0mm ETT)-extremely difficult ventilation Step 3: Immediate Femoral arterial-venous bypass	Ascending aorta and arch replacement with Hemashield tube graft and reimplantation of the brachiocephalic trunk and left common carotid using a bifurcated prosthesis	Extubated on POD 1
Khan, Muhammad J., et al. (April 2023)²³	37 years old, Male	Pseudoaneurysm in the proximal right subclavian artery (5x4x5 cm)	Significant tracheal narrowing (>70%)	Inhalational induction with airway topicalization allowing spontaneous breathing and C-MAC video laryngoscopy for ETT intubation. Followed by IV induction and FOB to guide the tube beyond stenosed area with ECMO back up	Repair of the pseudoaneurysm and bovine patch graft.	Extubated on 2^ndPOD

Overall, this case emphasizes the importance of early diagnosis, prompt surgical intervention, and effective teamwork in managing rare and potentially life-threatening conditions like mycotic pseudoaneurysms. It also highlights the critical role of anesthesiologists in providing optimal perioperative care, ensuring hemodynamic stability, managing airway challenges, and facilitating successful surgical outcomes.

ETT- endotracheal tube;

SICU- Surgical Intensive Care Unit;

GA- General Anesthesia;

CPB- cardio-pulmonary bypass;

IPPV- Intermittent Positive Pressure Ventilation;

HFJV- High frequency jet ventilation;

OR- operation room;

POD- post-operative day;

FOB- fiberoptic bronchoscope;

TAA- thoracic aortic aneurysm;

ECMO- Extracorporeal membrane oxygenation;

Ethics Approval

The Medical Research Centre of Hamad Medical Corporation reviewed and granted approval for this case report under ID MRC-04-23-437.

Patient’s consent

A written informed consent was obtained from the patient for the publication of this case report.

Availability of data and materials

Not applicable

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable

Authors' contributions

All authors listed have contributed sufficiently to the project to be included as authors. I have full access to all aspects of the research and writing process, and take final responsibility for the paper.

Acknowledgements

Not applicable

Corresponding author: Temur Baykuziyev,

email: [email protected]

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No competing interests reported.

Managing the Unpredictable: Airway and Anesthetic Challenges in a Patient with an Expanding Recurrent Mycotic Pseudoaneurysm of the Right Brachiocephalic Artery- A case report and literature review.

Status:

Version 1

Abstract

Figures

Background

Case Presentation

Anesthetic Technique:

Intraoperative Course:

Postoperative Management:

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1