When the Conception of Symmetry Deceives Us: A Case Report on the Perioperative Diagnosis of Subclavian Artery Stenosis.

Subclavian artery stenosis is a relatively uncommon manifestation of peripheral artery disease with significant morbidity. We describe a case of left subclavian artery stenosis that became apparent in the intraoperative setting, in a patient who presented for emergency surgery after a fall and subsequent left femoral neck fracture. Initial non-invasive blood pressure readings on the left upper extremity were in the normal range but after placement of the arterial line on the right upper extremity, the discrepancy was evident pointing towards a structural abnormality as the causative factor. CT angiography was found to confirm the diagnosis of left subclavian artery stenosis of an atherosclerotic nature. A thorough physical examination can point to the presence of subclavian stenosis through pulse amplitude and blood pressure asymmetries. This study highlights the importance of obtaining blood pressure readings ideally on all four limbs to avoid misinterpretation of blood pressure values that could ultimately lead to the use of unnecessary and inadequate interventions and possible complications in the perioperative setting.

Synergic Difficulties in an Anticipated Physiologically and Anatomically Difficult Airway in a Trauma Patient: A Case Report.

The American Society of Anesthesiologists (ASA) defines a difficult airway as a clinical situation in which a physician who is trained in anesthesiology experiences difficulty or fails in either face mask ventilation, laryngoscopy, using a supraglottic airway, tracheal intubation, extubation, or front-of-neck airway. Classically, this has been defined in relation to anatomic factors, but the concept of a physiologically difficult airway has been growing in relevance, in which physiologic factors, such as hypoxemia and hypercapnia, act to reduce safe apnea times. The case reports on a trauma patient with an unstable thoracic vertebral fracture requiring correction via the posterior approach. Our patient had multiple anatomical difficult airway predictors, namely, a short neck, greatly limited neck mobility, and a Mallampati class IV airway, among others, and multiple physiological difficult airway predictors, such as a baseline hypoxemic respiratory failure and severe sleep apnea, in addition to the restrictions on mobility imposed by the fracture itself. We describe a successful perioxygenation strategy, using high-flow nasal oxygen (HFNO) during the preoxygenation, intubation, extubation, and post-anesthesia care phases, and with an awake fiberoptic intubation technique for securing the airway.