Giant Aortic Arch Aneurysm: Preoperative Three-dimensional Airway “Roadmap” for Safe Intubation

The incidence of thoracic aortic aneurysms is increasing, in part because of the increasing availability of better imaging techniques. Figure 1 shows preoperative imaging of a 23-yr-old woman diagnosed with a distal aortic arch aneurysm extending to the proximal descending thoracic aorta (maximum diameter, 64 mm). Three-dimensional airway reconstruction (fig. 1C) confirmed leftward tracheal narrowing at the upper intrathoracic trachea, approximately 2 cm above the carina, classified as Myer–Cotton grade I,1 with normal caliber of both main bronchi.Fig. 1.: Preoperative anterolateral computed tomography angiography (A), axial computed tomography (B), and three-dimensional airway reconstruction (C) images reveal a distal aortic arch aneurysm extending to the proximal thoracic aorta, causing main tracheal extrinsic compression.These imaging findings provided an airway “roadmap” by defining the site and degree of tracheal compression and the feasibility of lung-isolation strategies. The patient was scheduled for partial aortic arch replacement and thoracic aortic aneurysm resection via left thoracotomy. Flexible bronchoscopy was used to verify the tracheal stenosis, which was consistent with preoperative three-dimensional reconstruction findings. A 35-French left double-lumen endotracheal tube was successfully inserted under flexible bronchoscopy guidance. After aneurysm resection and vascular reconstruction, repeat flexible bronchoscopy demonstrated marked improvement of tracheal stenosis with near-normal caliber and no residual tracheomalacia or airway collapse. Giant aortic arch aneurysms can cause life-threatening airway compression, posing significant challenges for perioperative anesthesia management. Preoperative three-dimensional airway reconstruction provides precise anatomic details of airway compression, aiding in the selection of intubation strategies.2 In clinical practice, coronal plane reconstruction and multiplanar reconstruction can be applied in conjunction with virtual endoscopy. The lesion site is first localized via virtual endoscopy, with synchronous positioning across axial, sagittal, and coronal planes, and the axial plane further enables the precise determination of stenosis severity and anatomical position. Intubation must be flexible bronchoscopy guided, with preference for a small-sized tracheal tube, and should be performed gently enough to avoid aneurysm rupture. If double-lumen tube placement fails, a single-lumen bronchial tube combined with a bronchial blocker or venoarterial extracorporeal membrane oxygenation invasive airway support may be considered. Intraoperative flexible bronchoscopy is crucial for verifying airway patency, guiding tube placement, and detecting postoperative tracheomalacia.3 The synergistic use of preoperative three-dimensional imaging and intraoperative flexible bronchoscopy ensures perioperative airway safety, minimizing the risk of airway-related adverse events. Research Support This work was supported by the Construction Project of High Level Hospital of Jiangsu Province (LCZX202505; Xuzhou, Jiangsu Province, China) and Project of Jiangsu Province Key Laboratory of Anesthesiology and Brain Science (XZSUSKF2025002). Competing Interests The authors declare no competing interests.