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LETTER TO THE EDITOR Table of Contents   
Year : 2007  |  Volume : 10  |  Issue : 2  |  Page : 155
Anaesthetic management for endovascular repair of a giant innominate artery pseudoaneurysm eroding into a mediastinal tracheostomy


Department of Anaesthesiology & Critical Care (Cardothoracic Section) Hospital of the University of Pennsylvania 3400 Spruce Street, Philadelphia, PA 1964-4283., USA

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How to cite this article:
Augoustides JG. Anaesthetic management for endovascular repair of a giant innominate artery pseudoaneurysm eroding into a mediastinal tracheostomy. Ann Card Anaesth 2007;10:155

How to cite this URL:
Augoustides JG. Anaesthetic management for endovascular repair of a giant innominate artery pseudoaneurysm eroding into a mediastinal tracheostomy. Ann Card Anaesth [serial online] 2007 [cited 2019 Dec 6];10:155. Available from: http://www.annals.in/text.asp?2007/10/2/155/37944


To,

The Editor,

Our group has published in the surgical literature successful management of a giant innominate artery pseudoaneurysm that had begun to erode into a mediastinal tracheostomy. [1] The anaesthetic plan required no airway manipulation, cardiopulmonary bypass, and precise control of the anaesthetic duration. The purpose of this letter is to describe the anaesthetic decision-making in more detail for the possible benefit of anaesthesia providers who may face similar cases in the future, given the explosion in endovascular aortic therapy.

The patient was a 16-year-old boy who developed tracheal stenosis and tracheal innomiate fistula after radiation for lymphoma. Surgical management ultimately required ligation of the innominate artery and mediastinal tracheostomy. The subsequent pseudoaneurysm was managed with serial endovascular coiling.

The patient presented with haemoptysis secondary to erosion into the trachea from the giant pseudo­aneurysm. After extensive consultation, endovascular exclusion of the pseudoaneurysm was selected as the therapeutic intervention. The overall anaesthetic management was based as the following principles


   First Principle: No Airway Manipulation Top


The endovascular coils were visible in the stoma of the mediastinal tracheostomy. Clearly, any airway manipulation carried a substantial risk of opening a tracheal-innominate fistula with life-threatening exsanguination as a result. The anaesthetic plan thus depended on spontaneous ventilation, a 'no touch' airway approach, and full cardiopulmonary bypass, as explained in the next section.


   Second Principle: Cardiopulmonary Bypass Top


Cardiopulmonary bypass via the femoral artery and vein offered the following advantages: guaranteed oxygenation, the reality of an adequate anaesthetic without concern for spontaneous ventilatory drive, and stable haemodynamics for decompression of the pseudoaneurysm and ultimate endovascular exclusion. Thus, cardiopulmonary bypass was initiated after femoral vessel cannulation under local anaesthesia and systemic heparinization. Although the procedure might have been performed with sedation and local anaesthesia without cardiopulmonary bypass, this approach offered no rescue options, since any airway manipulation, in our judgement, was not a safe possibility. In the case, no oxygen was administered via the tracheostomy. Ventilation was guaranteed during cardiopulmonary bypass because full flows were adequately achieved, and successful gas exchange was confirmed with frequent blood gas analysis.


   Third Principle: Precise Control of Anaesthetic Duration Top


This was pivotal, because after the endovascular procedure was completed, the patient would have to emerge promptly from anaesthesia. This would allow spontaneous ventilation for separation from cardiopulmonary bypass. The mainstay of the anaesthetic was a remifentanil infusion, with low-dose isoflurane via the oxygenator during cardiopulmonary bypass and titrated vecuronium for neuromuscular blockade. This combination allowed prompt patient emergence within 5-10 minutes after the procedure was completed. The neuromuscular blockade was reversed with neostigmine and glycopyrrolate dosed according to body weight.

The patient was discharged home within 5 days after an uneventful recovery. The teaching points that emerge from this case are flexibility of the anaesthetic plan, cardiopulmonary bypass for noncardiac surgery, and precise pharmacological titration to meet all perioperative goals.

 
   References Top

1.Szeto WY, Fairman RM, Acker MA et al. Emergency endovascular deployment of stent graft in the ascending aorta for contained rupture of innominate artery Annals - of Cardiac Anaesthesia 2007; 10: 155 pseudoaneurysm in a pediatric patient. Ann Thorac Surg 2006; 81: 1872-1875.  Back to cited text no. 1    

Top
Correspondence Address:
John GT Augoustides
Department of Anaesthesiology & Critical Care (Cardothoracic Section) Hospital of the University of Pennsylvania 3400 Spruce Street, Philadelphia, PA 1964-4283.
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.37944

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