Bhandary SP, Papadimos TJ, Svensson LG, Sale S.
J Cardiothorac Vasc Anesth. 2015 Feb;29(1):142-5. doi: 10.1053/j.jvca.2013.08.010. Epub 2013 Dec 13. No abstract available.
PMID: 24332920 [PubMed – in process]
Select item 25468587
Comment from Dr. Hafil B. Abdulgani (Indonesia), section editor of Congenital Heart Surgery Journal Watch: The Kommerell’s diverticulum is an abnormal remnant of the left aortic arch and presents itself as an aneurysmal dilation of the proximal aberrant left or right subclavian artery. It is associated with congenital anomalies of the aortic arch such as a double aortic arch, left-sided arch with aberrant right subclavian or right-sided arch with aberrant left subclavian artery. A right-sided arch is formed by the right fourth pharyngeal arch and abnormal persistence of the right dorsal aorta. In this case report, incomplete regression of the distal left aortic arch between the left common carotid and the left subclavian artery represents the Kommerell’s diverticulum with an aberrant left subclavian artery taking off (described by cartoon drawing below).
Comprehensive preoperative anesthetic evaluation for coexisting cardiac anomalies along with perioperative anesthetic concerns, such as the airway, lung isolation, and extubation were described. Airway evaluation should include lower airway anatomy with potential chronic external compressive effects. Secondary bronchomalacia might exist and posed difficulties in lung isolation and extubation. It was advisable to perform bronchoscopy under anesthesia after induction to ascertain distal airway compression and formulate a plan for airway management. The authors’ approach is to use a double-lumen tube (DLT) if there is minimal compression with a patent mainstem bronchus opposite of the incision side. An endobronchial blocker can be used if significant airway compression precludes the use of DLT, and precautions should be taken that minimize the occlusive volume that is maintained to isolate the lung. Prolonged compressive effects on the airway could result in bronchomalacia with difficulty in extubation postoperatively due to dynamic collapse of the airway. Options such as postoperative, noninvasive ventilation and airway stenting could help in managing this difficult situation. An invasive arterial catheter should be placed in the non-aberrant subclavian artery and the femoral artery to monitor perfusion pressures proximally and distally. The authors routinely place large-bore intravenous access to facilitate rapid volume infusion in the event of significant bleeding. Arterial catheters needed to be placed on either side of the repair not only to look for the identification of post-repair coarctation but also to assist with distal perfusion while on cardiopulmonary bypass. In this patient, arterial blood pressure monitoring was done using the right brachial and left femoral arterial catheter. Right upper extremity arterial pressure monitoring was instituted to determine the perfusion pressure proximal to the clamp, i.e., to the brain and in the lower extremity pressure to monitor the perfusion distal to the clamp. In conclusion, the anesthesiologist must remain vigilant and recognize situations in which there may be a need to modify the anesthetic management based on patient stability, surgical preference, and/or institutional practice.