• W M Weightman and N M Gibbs.
• Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia; University of Western Australia, Crawley, Perth, Western Australia, Australia. Electronic address: william.weightman@uwa.edu.au.
• Br J Anaesth. 2018 Nov 1; 121 (5): 1166-1172.

BackgroundSeveral case reports have described anatomical variations that can cause difficulty with front-of-neck airway access, such as major vessels anterior to the trachea. The prevalence of these anomalies is unknown.MethodsWe screened 500 consecutive thoracic computed tomography (CT) scans in adult patients performed independently in any public hospital in Western Australia. The prevalence of major vessels anterior to the trachea in the anterior triangle of the neck was determined.ResultsIn the suprasternal notch, 264 CT scans (53%) demonstrated part of a major vessel anterior to the trachea, most commonly the brachiocephalic artery. At 10, 20, and 30 mm above the suprasternal notch, respectively, 126 (25%), 48 (9%), and 5 (1%) CT scans showed a major vessel anterior to the trachea. None showed a major vessel anterior to the cricothyroid membrane. In the suprasternal notch, a major vessel was anterior to the trachea in 10 of 120 CT scans (8%) that had a manubrio-cricoid distance <25 mm, and 108 of 116 CT scans (93%) that had a manubrio-cricoid distance >50 mm. In a logistic-regression model, increased length of trachea above the manubrium was a strong predictor of major vessels anterior to the trachea in the suprasternal notch, whilst sex, age, thoracic kyphosis, tracheal diameter, and the origin of the brachiocephalic artery were not strong predictors.ConclusionsIt is common for patients to have some portion of a major vessel anterior to the trachea at sites where an emergency tracheostomy might be performed.Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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