Position-dependent unilateral pseudohypotension during transesophageal echocardiography in a patient with a retroesophageal aberrant right subclavian artery undergoing transcatheter aortic valve replacement: a case report

Background An isolated fall in right radial pressure during transesophageal echocardiography (TEE) can occur in patients with a retroesophageal aberrant right subclavian artery (ARSA) and may be mistaken for systemic hypotension. We report such an event during transcatheter aortic valve replacement (TAVR), with continuous documentation of probe movement and arterial waveform changes. Case presentation A 74-year-old woman with critical aortic stenosis underwent transfemoral TAVR under general anesthesia. Preprocedural computed tomography angiography (CTA) had shown a retroesophageal ARSA. During TEE manipulation at an estimated depth of 45–50 cm, right radial pressure fell from 136/63 to approximately 47/42 mmHg. Left-arm cuff pressure was 94/54 mmHg, and carotid and femoral pulses remained palpable. Arterial-line troubleshooting and intravenous metaraminol did not restore the radial waveform. When we withdrew the probe toward 30 cm to reassess cardiac function, the waveform unexpectedly began to return. A later continuous recording started with a well-formed radial waveform and the probe deeper than the segment associated with the waveform changes. Slow withdrawal through this segment produced attenuation and loss of visible pulsatility, followed by its return with further withdrawal. Femoral arterial pressure remained 119–125/44 mmHg throughout these changes. Subsequent TEE was limited to positions that preserved the radial waveform. TAVR was completed, and no clinical evidence of right-arm ischemia or esophageal injury was documented before discharge on postoperative day 8. Conclusions Possible probe-related compression of a retroesophageal ARSA should be considered when right radial pulsatility changes during TEE while pressure elsewhere remains adequate. Review of arch-vessel anatomy on preprocedural CTA can help plan TEE use and arterial monitoring during TAVR. Comparing pressure in another vascular territory may prevent unnecessary escalation of vasoactive treatment.