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Anesth Analg 2002;95:558-560 © 2002 International Anesthesia Research Society
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Abstract |
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 Top Abstract IntroductionCase ReportDiscussionReferences |
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IMPLICATIONS: Airway compression from insertion of a transesophageal echocardiography (TEE) probe has been mostly limited to pediatric patients. We present a case of TEE-associated airway obstruction in an adult patient undergoing surgery for repair of a giant ascending aortic pseudoaneurysm.
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Introduction |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Transesophageal echocardiography (TEE) is an invaluable intraoperative diagnostic monitor that is safe and relatively noninvasive. However, insertion and manipulation of the TEE probe may cause a variety of complications (1–6). Airway compression from insertion of a TEE probe is reported, although this complication has been mostly limited to pediatric patients (1,2). We report a case of TEE-associated airway obstruction in an adult patient undergoing surgery for repair of a giant ascending aortic pseudoaneurysm.
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Case Report |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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A 55-yr-old woman (weight, 51 kg; height, 149 cm) with a giant ascending aortic pseudoaneurysm was scheduled for a replacement of the ascending aorta and an aortic mechanical valve. Two years before this operation, she had undergone aortic valve replacement for aortic regurgitation, a sequela of infectious endocarditis. The course after surgery was smooth until she developed superior vena cava syndrome, and her face became severely edematous. It was found that she had a giant ascending aortic pseudoaneurysm caused by a painless ruptured aortic dissection. The pseudoaneurysm was multilocular and occupied most of the upper mediastinum, reaching the trachea. The right atrium was compressed, causing the superior vena cava syndrome; however, the tracheal internal lumen was patent with a slight change in its shape (Fig. 1A) by the pseudoaneurysm. She had no respiratory or upper gastric symptoms. In addition, there was a serious aortic perivalvular leakage. Based on the above findings, there was a risk that median sternotomy could cause inadvertent acute rupture of the substernal pseudoaneurysm. Profound hypothermic cardiopulmonary bypass (CPB) with femoral artery and vein cannulation was planned before opening the sternum. Because a vent catheter insertion to the left ventricle under thoracotomy was also planned, one-lung ventilation was required.
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Anesthesia was induced with propofol and fentanyl. After adequate muscle relaxation with vecuronium, an endotracheal tube with a built-in bronchial blocker (Univent®; Fuji Systems, Tokyo, Japan) was inserted for one-lung ventilation. Bronchoscopy, performed to assist proper positioning of the bronchial blocker, revealed that the trachea was slightly collapsed. After the insertion of a nasogastric tube, the peak inspiratory pressure increased from 25 cm H2O to 40 cm H2O. The discharge of gastric contents from the nasogastric tube was confirmed. Without trying to find the cause of increased airway pressure, the tidal volume was decreased, and a TEE probe (Omni Plane II®, 10.5 mm in diameter with the chip, 14.5 mm wide, 11.5 mm in height, and 42 mm long; Philips Medical Systems, Best, the Netherlands) was directly inserted into the esophagus with the aid of a laryngoscope. When the tip of the TEE probe was advanced to the depth of approximately 22 cm from the incisors, airway obstruction was noticed. Bronchoscopy revealed that the tracheal tube was patent, but the trachea was completely collapsed. The TEE probe and the nasogastric tube were then immediately removed, and mechanical ventilation was resumed. Thereafter, anesthetic management was without any difficulty.
Before weaning from the CPB, the patency of the trachea was confirmed by bronchoscopy, and the TEE probe was reinserted. After fiberoptic visualization showed tracheal patency, the airway pressure did not increase at the time of sternum closure, and a TEE examination was performed under normal conditions.
The postoperative course was uneventful, and there were no other complications related to the TEE probe insertion. She was tracheally extubated on postoperative Day 3 and discharged from the intensive care unit the next day. Three weeks after the operation, enhanced computed tomography (CT) showed that the trachea had been decompressed as a result of the pseudoaneurysmectomy (Fig. 1B).
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Discussion |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Although TEE is a relatively safe diagnostic and monitoring tool for the management of cardiac surgical patients (1,2), careful insertion and manipulation of the probe are recommended. In most studies, minor complications from TEE, such as lip injury, dental injury, hoarseness, dysphasia, and odynophagia, have been reported. The incidence of these events is approximately 0.1%–13% (1,2). Serious complications, such as esophageal injury, vocal cord paralysis, arrhythmia, and hypotension, occur in <3% of TEE examinations (1,2). However, in specific circumstances, TEE may cause serious and even fatal complications. Hypopharyngeal perforation, esophageal perforation, gastric laceration, splenic laceration, and rupture of dissecting thoracic aneurysm are very rare but serious and life threatening complications (1–6).
Respiratory complications because of TEE occur more frequently in awake examinations or in small children in whom the membranous part of the trachea is easily compressed by the probe (1). In an adult cardiac surgical patient under general anesthesia, respiratory complications because of TEE are rare. In a single-center series of 7200 cardiac surgical patients, the endotracheal tube was inadvertently advanced into a right mainstem bronchus during probe manipulation in two patients (2). In another adult patient with a dissecting aneurysm of the ascending aorta and arch, a left-sided double-lumen endotracheal tube was inserted, and the TEE probe locked in a flexed position compressed the membranous part of the trachea (7). This report indicated that excessive flexion of the TEE probe might have induced respiratory compromise. However, there have been no reports of airway obstruction by only TEE probe insertion without flexion in an adult cardiac surgical patient under general anesthesia.
Preoperatively, the trachea was slightly compressed by the pseudoaneurysm, but the tracheal internal lumen was patent, and the patient had no signs of respiratory or gastrointestinal tract obstruction. Thoracic aortic aneurysm with a serious aortic perivalvular leakage is a Category I indication for TEE (1), and we considered intraoperative TEE to be potentially useful during pseudoaneurysmectomy. Based on these considerations, we decided to insert the TEE probe. Retrospectively, because the initial fiberoptic visualization after intubation showed tracheal collapse, it might have been prudent not to insert the probe.
Giant pseudoaneurysm developing after a painless ruptured chronic aortic dissection after aortic valve replacement is very rare (8,9) but can be a contributing factor for TEE-associated airway obstruction. We speculate that in this case, the trachea had been slightly collapsed between this giant pseudoaneurysm and the vertebral body (Fig. 1A) and that when the membranous part of the trachea was subsequently compressed by the TEE probe, total obstruction of the trachea occurred. After repair of the pseudoaneurysm, the patency of the trachea was confirmed by bronchoscopy, TEE was performed under normal conditions, and enhanced CT showed the trachea had been decompressed by performance of the pseudoaneurysmectomy (Fig. 1B). In aggregate, these findings support our hypothesis.
There was no inadvertent tracheal placement of the nasogastric tube and the TEE probe because the discharge of gastric contents from the nasogastric tube was confirmed, and the TEE probe was inserted into the esophagus under direct laryngoscopic visualization. In addition, these devices were not found by bronchoscopy when the airway obstruction was evaluated. Furthermore, the probe size was suitable for our patient (weight, 51 kg; height, 149 cm), consistent with unremarkable performance of TEE after repair of the pseudoaneurysm.
In summary, this case demonstrates TEE-associated airway obstruction in a patient undergoing surgery for repair of a giant ascending aortic pseudoaneurysm. The indication for TEE monitoring should be carefully considered in the presence of tracheal compression by any structure such as a giant pseudoaneurysm.
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References |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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- Thys DM, Abel M, Bollen BA, et al. Practice guidelines for perioperative transesophageal echocardiography: a report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 1996; 84: 986–1006.[Web of Science][Medline]
- Kallmeyer IJ, Collard CD, Fox JA, et al. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg 2001; 92: 1126–30.
[Abstract/Free Full Text] - Spahn DR, Schmid S, Carrel T, et al. Hypopharynx perforation by a transesophageal echocardiography probe. Anesthesiology 1995; 82: 581–3.[Web of Science][Medline]
- Latham P, Hodgins LR. A gastric laceration after transesophageal echocardiography in a patient undergoing aortic valve replacement. Anesth Analg 1995; 81: 641–2.[Web of Science][Medline]
- Chow MS, Taylor MA, Hanson CW 3rd. Splenic laceration associated with transesophageal echocardiography. J Cardiothorac Vasc Anesth 1998; 12: 314–6.[Web of Science][Medline]
- Dalby Kristensen S, Ramlov Ivarsen H, Egeblad H. Rupture of aortic dissection during attempted transesophageal echocardiography. Echocardiography 1996; 13: 405–6.[Medline]
- Nakao S, Eguchi T, Ikeda S, et al. Airway obstruction by a transesophageal echocardiography probe in an adult patient with a dissecting aneurysm of the ascending aorta and arch. J Cardiothorac Vasc Anesth 2000; 14: 186–7.[Web of Science][Medline]
- Seki K, Abe T, Kuribayashi R, et al. Aortic dissection with giant pseudoaneurysm as a rare late complication of aortic valve replacement: a case report (In Japanese). Nippon Kyobu Geka Gakkai Zasshi 1994; 42: 1382–7.[Medline]
- Derkac W, Laks H, Cohn LH, Collins JJ Jr. Dissecting aneurysm after aortic valve replacement. Arch Surg 1974; 109: 388–90.
[Abstract/Free Full Text]
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