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.

Abstract

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.