Anesthetic Management of the Resection of a Kommerell’s Diverticulum

CASE REPORTA 66-year-old woman (159 centimeter, 59 kilogram) presented tothe authors’ institution with a history of difﬁculty swallowing, chestpressure, and heartburn of increasing severity. She was diagnosed witha KD by magnetic resonance imaging (MRI), which demonstrated anaberrant left SC artery with a right-sided aortic arch. The left commoncarotid artery arose as the ﬁrst branch from the distal ascending aortafollowed by the right common carotid, right vertebral, and rightsubclavian artery. The left subclavian artery originated as the lastbranch with a 2.3-cm aneurysmal dilation of its proximal segmentconsistent with KD. The aberrant artery had a retroesophageal courseresulting in moderate compression of the esophagus and mild com-pression of the trachea as seen in the MRI (Fig 1). There was noevidence of dissection, rupture, or leak. Her past medical history wassigniﬁcant for hypertension, hyperlipidemia, hiatal hernia, gastroeso-phageal reﬂux disease, hypothyroidism, and obstructive sleep apnea.Her medications consisted of ramipril, levothyroxine, and hydrochlor-othiazide. Physical examination was unremarkable and laboratoryresults were within normal limits. Preoperative transthoracic echocar-diogram revealed normal biventricular function without signiﬁcantvalvular abnormalities. The patient was scheduled for resection of theKD and repair of the aorta.After applying ASA monitors, the patient was premedicated with2 mg of intravenous midazolam. A right radial arterial catheter wasplaced to monitor arch pressures. Blood pressure was equal in bothupper extremities. A pulse oximeter probe was placed on the left handin order to monitor limb perfusion indirectly. A rapid-sequenceinduction was performed using propofol, fentanyl, and succinylcholinefollowed by intubation with a 7.5-mm endotracheal tube. This wasfollowed by a ﬁberoptic examination of the airway that revealed mildcompression of the right main bronchus with a normal-appearingtrachea and left main bronchus. Subsequently, the single-lumenendotracheal tube was changed to a 37Fr left-sided double-lumen tubeassisted by video laryngoscope and a 14Fr soft-tipped airwayexchanger. A double-lumen tube was guided into position underﬁberoptic guidance and positioned without difﬁculty. Anesthesia wasmaintained with isoﬂurane in oxygen, and the patient tolerated single-lung ventilation. A left femoral arterial catheter was placed to monitordistal perfusion as needed. A pulmonary artery catheter was insertedthrough a 9Fr multi-lumen introducer. In view of her normal cardiacstudies and symptomatic esophageal compression, which had worsenedsince her esophagoscopy, a transesophageal echocardiography probewas not placed. Right femoral vessels were exposed before chestincision to facilitate peripheral cannulation. A right thoracotomyapproach was used to dissect the distal arch and descending aorta.The ascending aorta was cannulated, and the cardiopulmonary systemwas bypassed with venous drainage through a multi-oriﬁced catheteradvanced to the right atrium from the right femoral vein (Fig 2). Thedecision not to perform distal perfusion was made by the team in viewof the short segment required to be replaced without interfering withintercostal circulation and also satisfactory preoperative distal organfunction. Cardiopulmonary bypass (CPB) with mild hypothermia,temperature in the range of 32-34oC, was implemented because thediseased arch had a potential for disruption. CPB also facilitatedmediastinal dissection by maintaining systemic perfusion duringexternal cardiac compression.The distal arch and descending aorta were repaired with interpositionof a hemashield graft without sacriﬁcing any intercostal arteries after theKD was ligated and then over-sewn. The aberrant left subclavian arterywith the attached ligamentum arteriosum was dissected, thus, decom-pressing the esophagus. Aortic unclamping did not result in signiﬁcanthypotension and could be controlled with a low-dose vasopressor onCPB. Total CPB time was 65 minutes with an aortic clamp time of 47minutes. Separation from the cardiopulmonary bypass was uneventful.At the end of the procedure, the double-lumen endotracheal tube wasswitched to a single-lumen tube. The patient was transferred to theintensive care unit and extubated on postoperative day 1. Postoperativeanalgesia was achieved with intermittent boluses of a narcotic. Post-operative neurologic assessment was normal.DISCUSSION