INTRODUCTION: Right sided aortic arch (RSAA), aberrant left subclavian artery (aLSA), dilated origin of the LSA (Kommerell's diverticulum), and persistent left superior vena cava (LSVC) usually manifests in individuals younger than 35 years. Symptoms of tracheal or esophageal compression are common manifestations. These vascular malformations were discovered in an elderly patient who developed respiratory distress after tracheostomy tube (TT) change.
CASE PRESENTATION: A 70-year male with COPD, on home BiPAP ventilation for sixteen months was admitted to MICU following TT change to an uncuffed long distal tube. He was cyanotic, tachypneic, tachycardic, and anxious. Venous gasometry revealed: pH 7.33, pCO2 74.3 mmHg, and pO2 26 mmHg on FiO2 0.4. TT was changed to a cuffed one, and his respiratory distress improved. Bronchoscopy showed 80% occlusion at the distal end of the TT by a protuberant membranous trachea. CT chest demonstrated RSAA with, aLSA, and Kommerell's diverticulum causing anterior esophageal and tracheal displacement. On sagittal views, the TT tube was seen to be partially occluded by the displaced membranous trachea. In addition, a persistent LSVC was found. Later, a short distal TT was placed 2 cm proximal to the membranous protuberance. Thereafter respiratory symptoms improved.
DISCUSSIONS: There are limited reports of the constellation of vascular anomalies found in our patient. Autopsy series indicate a 3% frequency of anomalies of the aortic arch and its branches. These anomalies are usually asymptomatic, being an incidental radiological finding, except when they cause tracheal or esophageal compression. Respiratory symptoms are more common in children, whereas dysphagia is the most common symptom in older patients. Tracheal compression by a Kommerell's diverticulum mimicking bronchial asthma has also been described. Pain in the thorax, shoulders, and neck, as well as ischemia of the left upper extremity has been reported. Initial suspicion of these vascular malformations can be confirmed by CT or MRI. Arteriography is reserved for patients requiring corrective surgery. Resection of the diverticulum and the aberrant vessel followed by reanastomosis with one of the nearby large vessels usually has satisfactory results. To our knowledge, respiratory distress secondary to TT occlusion in these patients, and the presence of LSVC in association with RSAA and aLSA have not been described.
CONCLUSION: The presence of a right sided aortic arch with an aberrant left subclavian artery and Kommerell's diverticulum has to be considered in patients endotracheally intubated presenting with occlusion of the distal opening of the endotracheal tube.
DISCLOSURE: Shahida Bashir, No Financial Disclosure Information; No Product/Research Disclosure Information