Pulmonary Artery Sling: Anesthetic Challenges and Fast Track Technique

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This is the first case of pulmonaryartery (PA) sling with tracheal stenosis to be reported in our center, Ain shams University hospital for the past 10 years, although our experience with cardio-thoracic surgery started over 60 years, we still don’t have reported cases and formulated anesthetic technique for PA sling procedures. We are fully aware that this pathology is very rare and it could account for less than 1% of congenital heart diseases candidates for corrective surgeries. Vascular rings are a nightmare for most of anesthesiologists as it is may affect the trachea causing tracheal stenosis and obstruction. The exact pathology of pulmonary artery sling is that the left pulmonary artery (LPA) arises from the distal origin of the right pulmonary artery (RPA), the LPA runs in a tortuous retro-tracheal location causing posterior compression on the trachea in the pre-carinal level.

2 years old, 10kilograms, male infant presented with marked airway obstruction and repeated chest infection not responding to medical treatment, investigations revealed a PA sling with tracheal stenosis measuring 4.0mm (Figure 2), with complicated functional atrial septal defect (ASD). Surgical team decided to go for a definitive repair of the sling and relief the compression on cardio-pulmonary bypass. Airway management was crucial for fear of tracheomalacia, preoperative fiberoptic bronchoscope was irrelevant, chest radiographs revealed right lung consolidations and tracheal stenosis just above the carina as mentioned, but there were no signs or symptoms of severe airway obstruction or stridor, chest examination revealed bilateral inspiratory rhonchi and coarse Crepitations, sepsis markers as c-reactive protein were negative and no signs of active infection was present, Echocardiography revealed ASD measuring 4.9mm with normal pulmonary artery pressure besides the PA sling, other laboratory profile were unremarkable, so we decided to start inhalational induction and insert an armored tube size 4mm ID without difficulty and ventilated on a pressure support mode, P insp 12 and applying 5 Cm H20 PEEP, lung recruitment maneuver was needed after induction by ET tube suctioning, bronchodilators, and Dexamesthasone 2mg iv, ETCO2 is maintained 25-30 mmHg throughout the operation.