Tracheal Obstruction Upon One Lung Ventilation in Patient With Right-sided Aortic Arch and Kommerell's Diverticulum

Kommerell’s diverticulum (KD) is a rare congenital anomaly of the aortic arch. It usually refers to the aneurysmal outpouching at the origin of an aberrant left subclavian artery in the setting of a right-sided aortic arch.... [ view full abstract ]

Kommerell’s diverticulum (KD) is a rare congenital anomaly of the aortic arch. It usually refers to the aneurysmal outpouching at the origin of an aberrant left subclavian artery in the setting of a right-sided aortic arch. The presentation is often asymptomatic, but can cause symptoms of esophageal or tracheal obstruction. If left untreated, the major complications can include dissection or even rupture. While tracheal compression has been previously described preoperatively or after induction of anesthesia, few case reports have described tracheal obstruction that manifested after initiation of one lung ventilation.

Our case describes a 32 year old woman who presented for surgical correction of her aberrant left subclavian artery and 18 mm KD, which was causing proximal esophageal compression. A 37 Fr Mallinckrodt left-sided double-lumen endotracheal tube (DLT) was placed for the case after induction of anesthesia. After initiation of one lung ventilation by clamping the left bronchial lumen, there was significant difficulty with ventilation. Upon examination, the posterior wall of the trachea was found to be protruding inward distal to the tracheal lumen. This airway compression caused increased airway pressures upon one lung ventilation, and difficulty maintaining adequate tidal volumes for oxygenation and gas exchange.

This case report highlights the utility of assessing for airway obstruction via fiberoptic bronchoscopy, as well as suggests that the use of a right-sided DLT should be considered in patients with right-sided aortic arch, regardless of degree of airway obstruction noted prior to induction of anesthesia.