Anesthetic Induction Strategy for a Patient with a Giant Aortic Arch Aneurysm Compressing the Main Airway: A Case Report

Asploro Journal of Biomedical and Clinical Case Reports

ISSN: 2582-0370
Article Type: Case Report
DOI: 10.36502/2025/ASJBCCR.6419
Asp Biomed Clin Case Rep. 2025 Aug 20;8(3):240-42

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Xiao Bai^1*
¹Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China

Corresponding Author: Xiao Bai
Address: Department of Anesthesiology, West China Hospital, Sichuan University, No. 37, Guoxue Valley, Wuhou District, Chengdu, Sichuan 610041, China.
Received date: 10 August 2025; Accepted date: 15 August 2025; Published date: 20 August 2025

Citation: Bai X. Anesthetic Induction Strategy for a Patient with a Giant Aortic Arch Aneurysm Compressing the Main Airway: A Case Report. Asp Biomed Clin Case Rep. 2025 Aug 20;8(3):240-42.

Copyright © 2025 Bai X. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Aortic Arch Aneurysm, Airway Compression, Anesthetic Induction, Remimazolam, Succinylcholine

Abstract

Isolated aortic arch aneurysms are relatively rare, accounting for 21.3% of thoracic aortic aneurysms. However, with an aging population and advancements in imaging technology, the detection rate of aortic arch aneurysms has gradually increased. Key risk factors include age, gender, hypertension, atherosclerosis, hereditary connective tissue disorders, and infections. A giant aortic arch aneurysm is not only a “ticking time bomb” within the patient but also poses significant challenges for anesthesiologists when associated with airway compression, which can lead to airway and circulatory collapse during induction. We report a case of a 52-year-old male who presented with chest pain; imaging revealed a giant aortic arch aneurysm compressing the main airway. The patient underwent total aortic arch replacement under general anesthesia, with a successful surgery. We share this case to discuss the anesthetic induction process and insights for managing aortic arch aneurysms with airway compression.

Introduction

While aortic arch aneurysms are rare, their potential rupture risk and compression of adjacent structures by an enlarging mass severely threaten the patient’s life. Common etiologies include atherosclerosis, hereditary connective tissue disorders, infections, inflammatory diseases, and trauma. For patients with arch aneurysms exceeding 5.5 cm in diameter or exhibiting significant compressive symptoms, surgical intervention is imperative alongside the management of atherosclerotic risk factors [1]. Giant aortic arch aneurysms with compression pose significant challenges for anesthesiologists, particularly during anesthetic induction.

Case Presentation

A 52-year-old male presented with a 3-month history of chest pain. The patient habitually slept in a high-pillow or right lateral decubitus position and could tolerate supine positioning only briefly (approximately 20 minutes). On room air, his oxygen saturation was 96%, with slightly diminished breath sounds bilaterally and a respiratory rate of 25 breaths/minute. No jugular venous distension was observed. He experienced dyspnea on exertion after walking approximately 50 meters.

Diagnostic Imaging Findings:

Aortic CTA revealed an aortic arch aneurysm measuring 8 cm in maximum diameter, causing rightward tracheal displacement and severe compression of the main airway (narrowest point: 1 mm).
Transthoracic echocardiography indicated normal cardiac structure and hemodynamics.
Coronary CTA showed no significant coronary artery stenosis.

The Patient’s Admission Diagnosis:

Giant aortic arch aneurysm.

Planned Intervention:

Total aortic arch replacement.

Anesthetic Induction Process

During the anesthetic induction of this patient, we implemented a titrated, stepwise strategy [2]. Upon entering the operating room, pillows were placed to elevate the patient’s left torso, creating a mild rightward tilt, while the head of the bed was raised to 30 degrees to maintain a semi-recumbent position that optimized respiratory comfort. After adequate local anesthesia, ultrasound-guided arterial and right internal jugular venous lines were established, with simultaneous Bispectral Index (BIS) monitoring.

Once vascular access was secured, oxygen flow was increased to 10 L/min for thorough preoxygenation during spontaneous breathing. When end-tidal oxygen concentration reached 100%, we administered 7 mg of remimazolam intravenously. The BIS gradually decreased to 65, while the patient maintained stable respirations at 18 breaths per minute and hemodynamic equilibrium. Subsequently, 10 μg of sufentanil was slowly injected. After five minutes of observation, neither respiratory rate nor circulation showed significant changes. A second 10 μg dose of sufentanil was then slowly administered; five minutes later, the respiratory rate declined gradually to 12 breaths per minute. Following an additional 1 μg of sufentanil and another five-minute observation period, the respiratory rate further decreased to 8 breaths per minute, with stable heart rate and blood pressure.

At this juncture, gentle jaw thrust was applied, and positive-pressure ventilation was delivered during the expiratory pause. With an inspiratory pressure of 25 cmH₂O, a tidal volume of 550 mL was achieved. Finally, 50 mg of succinylcholine was administered. After fasciculations subsided, a 6.5-mm endotracheal tube was placed through the glottis using a video laryngoscope. Fiberoptic bronchoscopy then guided the tube through the narrowest segment (1 mm) of the compressed main airway, ultimately positioning the tip approximately 1 cm above the carina.

Following successful intubation, pressure-controlled ventilation–volume guaranteed (PCV-VG) mode was initiated. Adequate ventilation was maintained with a tidal volume of 400 mL at a mean airway pressure of 15 cmH₂O.

Discussion

The primary challenges during anesthetic induction for this patient centered on two critical risks. First, the airway risk—prolonged compression of the main airway by the giant aortic arch aneurysm could lead to tracheomalacia. Routine induction might cause complete airway collapse, resulting in asphyxia. Second, the circulatory risk—sudden hypertension or hypotension during induction could trigger dissection or rupture of the aneurysm. While awake fiberoptic intubation with preserved spontaneous breathing offers advantages for patients with significant airway compression, this approach carries substantial limitations: inadequate analgesia during awake intubation may provoke significant hemodynamic fluctuations, potentially triggering rupture of the aortic arch aneurysm.

In this patient’s induction process, medications were administered sequentially with strict titration. Remimazolam was selected over traditional benzodiazepines due to its lower incidence of respiratory depression and hypotension [3]. If respiratory or circulatory compromise occurred during initial sedation, flumazenil could rapidly reverse its effects, allowing immediate awakening [4]. After achieving the target Bispectral Index (BIS) depth, sufentanil was cautiously titrated to assess tolerance to manual ventilation. If face-mask ventilation proved difficult, the patient could be awakened; conversely, if ventilation was smooth, neuromuscular blocking agents were administered. While sufentanil effectively suppresses stress responses and maintains hemodynamic stability, respiratory depression remains a risk during induction [5]. Succinylcholine, a short-acting neuromuscular blocker with a plasma half-life of 2 – 4 minutes and clinical duration of 5 – 10 minutes, provided a critical safety advantage: in the event of failed intubation, its rapid offset permits emergency awakening even after full paralysis—unlike intermediate/long-acting relaxants that preclude reversal.

Conclusion

For patients with airway compression caused by mediastinal masses, awake intubation with preserved spontaneous breathing—despite potential hemodynamic fluctuations—remains a safe and reliable approach. However, when the compressing structure is an aortic arch aneurysm, such circulatory instability may trigger lethal complications. Consequently, a stepwise, titrated induction strategy offers distinct advantages.

The protocol employing remimazolam for sedation, sufentanil titration to assess ventilation tolerance, and succinylcholine for rapid-sequence intubation preserves spontaneous respiration until the final moment, thereby reducing risks of both airway collapse and circulatory crisis. Fiberoptic bronchoscopy ensures precise navigation of the endotracheal tube through the narrowest airway segment, minimizing injury to the compromised trachea. This induction approach provides a safe framework for patients with thoracic aortic aneurysms compressing the airway.