# Intraoperative transesophageal echocardiography under aortic arch branch blood flow monitoring in a patient with an aberrant left subclavian artery: a case report

## TL;DR

A patient with a rare blood vessel anomaly safely underwent a heart imaging procedure during surgery with proper monitoring.

## Contribution

This case demonstrates a safe approach to TEE in patients with an aberrant left subclavian artery using imaging and monitoring.

## Key findings

- TEE was safely performed in a patient with a right-sided aortic arch and ALSA.
- Bilateral radial arterial pressures and cerebral oxygen saturation monitoring were effective.
- No neurological or upper-limb deficits occurred post-surgery.

## Abstract

Transesophageal echocardiography (TEE) is widely used in cardiac and non-cardiac surgeries with major hemodynamic fluctuations. In patients with vascular anomalies near the esophagus, such as an aberrant left subclavian artery (ALSA), TEE may pose a risk of vascular compression. However, no guidelines exist.

Case presentation.

A 19-year-old woman with biliary atresia underwent living donor liver transplantation. Preoperative imaging showed a right-sided aortic arch with ALSA coursing posterior to the esophagus, and ALSA compression was considered a risk during TEE. Therefore, bilateral radial arterial pressures and regional cerebral oxygen saturation (rSO₂) were monitored. The TEE probe was inserted under videolaryngoscopic guidance without resistance or hemodynamic disturbance, and no arterial waveform attenuation or rSO₂ changes occurred. Transplantation was uneventful, and the patient showed no postoperative neurological or upper-limb deficits.

This case highlights that appropriate imaging and monitoring strategies can support safe TEE use in non-cardiac surgery, even with vascular anomalies.