Management-changing diagnosis of presumed clamp-related brachiocephalic artery injury by transesophageal echocardiography during total aortic arch replacement: a case report

Background Aortic arch branch malperfusion during total aortic arch replacement requires prompt diagnosis. We report a case in which transesophageal echocardiography (TEE) clarified discordant intraoperative monitoring findings and directly guided surgical revision. Case presentation A 77-year-old woman underwent total aortic arch replacement. After separation from cardiopulmonary bypass, right radial arterial pressure and right regional cerebral oxygen saturation markedly decreased, whereas direct brachiocephalic arterial pressure remained preserved. Targeted TEE demonstrated brachiocephalic artery dissection extending into the right common carotid artery with true-lumen compression, loss of antegrade flow into the right subclavian artery, and retrograde vertebral collateral flow. These findings prompted immediate surgical revision. After reconstruction, arterial pressure and cerebral oxygen saturation recovered, and TEE confirmed restoration of antegrade flow. Conclusions Targeted TEE can clarify discordant monitoring findings in aortic arch branch malperfusion and provide critical information for intraoperative surgical decision-making.