Difficult Placement of Univent Tube(R) Blocker Due to Aberrant Right Subclavian Artery Aneurysm

There have been few reports on aneurysms of the anomalous branch of the aortic arch. We present a rare case in which correct placement of the movable blocker of a Univent tube(R) was difficult due to an aberrant right subelavian artery aneurysm. A 72-year-old man with a history of hypertension had manifested coughing and wheezing for four months prior to admission to our hospital. A chest computed tomogram revealed that his aortic arch had four branches and that the right subclavian artery did not originate from the first branch, but was the fourth branch. The angiogram disclosed that an aneurysm had developed in the anomalous artery close to the aorta, and behind the other three branches, trachea, and esophagus. The aneurysm not only had pushed the trachea out of place but was also pressing against it. After anesthetic induction, his trachea was intubated using an endotracheal tube with a movable blocker, the Univent tube(R), for single-lung ventilation. The blocker could not be advanced into the left main bronchus due to the tracheal deviation caused by the aneurysm. Several methods of blocker placement, including those recommended in the manual attached to the product, were attempted without success. Finally, the trachea was intubated again using a Univent tube(R) with the blocker tip bent manually, which permitted entrance of the blocker into the bronchus. Blocker placement should be modified to suit patients with a problem in the trachea or bronchi.