Anesthetic management of left brachiocephalic artery reimplantation in an infant: Role of cerebral oximetry in guiding ventilation, perfusion, and cannulation decisions

Isolated left brachiocephalic artery (ILBA) is a rarely reported congenital anomaly in which the left brachiocephalic artery (LBA) is connected to the pulmonary artery. Repair of this condition is challenging due to cerebral perfusion being dependent on the circle of Willis and the direct connection between the pulmonary artery and the systemic circulation. We report the case of a 9-month-old female diagnosed with type II ILBA, who underwent elective reimplantation of the LBA into the aorta. The anesthetic goals were to optimize cerebral circulation and prevent pulmonary overflow. Near-infrared spectroscopy (NIRS) was employed to monitor cerebral oxygenation. Major intraoperative decisions such as adjusting ventilation to induce hypercapnia, systemic cooling, optimizing cannula positioning, employing selective antegrade cerebral perfusion, deep hypothermic arrest, and gradual rewarming were all guided by NIRS monitoring. Postoperative recovery was uneventful, with extubation performed on the same day. This case highlights the importance of cerebral oximetry and emphasizes the critical role of NIRS as an indispensable tool for guiding ventilation, cerebral perfusion, and cannulation decisions, which should be the standard of care during complex aortic arch repairs.