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Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
LETTER TO EDITOR  
Year : 2011  |  Volume : 14  |  Issue : 3  |  Page : 239-240
Anesthesia for simultaneous bilateral aorto-axillary and coronary artery bypass grafting in Takayasu's arteritis


1 Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
2 Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication20-Aug-2011
 

How to cite this article:
Hegde HV, Arya VK, Thingam SK, Rana S. Anesthesia for simultaneous bilateral aorto-axillary and coronary artery bypass grafting in Takayasu's arteritis. Ann Card Anaesth 2011;14:239-40

How to cite this URL:
Hegde HV, Arya VK, Thingam SK, Rana S. Anesthesia for simultaneous bilateral aorto-axillary and coronary artery bypass grafting in Takayasu's arteritis. Ann Card Anaesth [serial online] 2011 [cited 2020 Jan 19];14:239-40. Available from: http://www.annals.in/text.asp?2011/14/3/239/84037


The Editor,

A 50-year-old, 47-kg male, diagnosed to be a case of Takayasu's Arteritis (TA) was scheduled for bilateral aorto-axillary bypass graft with coronary artery bypass grafting (CABG). He had a history of pain in the right upper limb on working and lifting weights since 10 years, and had a similar complaint in the left upper limb since 2 years. He had breathlessness on climbing two flights of stairs since 6 months and, also, three episodes of presyncope in the past 3 years. He was receiving Tab. Aspirin 150 mg, Amlodipine 5 mg, Atenolol 25 mg and Atorvastatin 10 mg once-daily and Isosorbide mononitrate 20 mg twice-daily.

On examination, no arterial pulses were felt in the upper limbs and the noninvasive blood pressure (NIBP) in the lower limb was 170/110 mmHg. The remainder of the physical examinations, routine investigations, chest X-ray and ECG were within normal limits. An echocardiography revealed left ventricular ejection fraction of 45%, hypokinesia of the right coronary artery (RCA) territory and right ventricular systolic pressure of 36 mmHg. A coronary angiogram showed 80% occlusion of the RCA and a normal left circumflex and left anterior descending artery. A computed tomography (CT)-angiogram showed normal carotids, complete occlusion of both subclavian arteries [Figure 1] and 60% stenosis of the right renal artery with involvement of the celiac axis and superior mesenteric and inferior mesenteric arteries.
Figure 1: Computed tomography angiogram showing occlusion of the bilateral subclavian arteries (arrows)

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In the operation theater, routine noninvasive monitoring was initiated and the oscillometric NIBP in the upper limb was 106/75 mmHg. The left dorsalis-pedis and the right femoral artery were cannulated and a double lumen central venous catheter was secured through the right femoral vein under local anesthesia and sedation (morphine 12 mg and midazolam 2 mg). BP measured through the dorsalis pedis and femoral artery were 205/103 and 146/80 mmHg, respectively. Pulmonary artery catheterization was attempted through the right femoral vein, which could not be negotiated beyond the right ventricle. Although arterial pulses were not felt in both the upper limbs, the pulse-oximeter showed an arterial saturation of 98-100%, as reported by Chawla et al. [1]

Anesthesia was induced with thiopentone 200 mg. Neuromuscular blockade was achieved with vecuronium 6 mg and tracheal intubation was carried out. Anesthesia was maintained with propofol infusion, supplemental doses of morphine and vecuronium. There were two episodes of bradycardia (heart rate = 34/min) that responded to atropine. Bilateral aorto-axillary bypass was carried out first using a PTFE graft, followed by right saphenous vein grafting to the RCA, which was performed under cardiopulmonary bypass with moderate hypothermia. The femoral arterial pressure was monitored and appropriate pressures were maintained with titrated doses of intravenous phenylephrine when necessary. The pupils were examined for signs of cerebral ischemia and no special neurological monitoring was used intraoperatively. The postoperative course was uneventful.

TA is a chronic, progressive, autoimmune disease with panaortitis, which results in stenosis or, less commonly, dilatation of the thoracic/abdominal aorta or both and stenosis or dilatation of the major arteries that arise from the aorta leading to compromised function of the major organs. TA predominately affects women (M:F = 1:8) and has an onset during the second or third decades of life. Coronary artery involvement, with incidence being similar in Indians (12%) and in other populations (10%), [2] has been considered a potentially fatal complication of TA. Although the anesthetic management of patients with TA for various elective/emergency surgical procedures has been described, [3] reports of CABG have been few. [4]

Anesthetic care of patients with TA for major surgical procedures is challenging. It requires meticulous planning, preoperative optimization, intensive monitoring of the cardiovascular system and maintaining perfusion to the brain and other organs. Invasive BP needs to be carefully monitored and interpreted because discrepancy in BP measured at different sites is common in TA. [5] Hence, central BP measured from larger proximal arteries is recommended to avoid injudicious use of vasodilators to "normalize" blood pressure, which could result in inadvertent cerebral hypoperfusion. Intensive cardiovascular monitoring is required as it has been observed that these patients may be more sensitive to myocardial depressants. [6] Unfortunately, PAC remained in RV as the design of PAC is not suitable for the femoral route and fluoroscopy was not available in the operation theater. Transesophageal echocardiography was not available. Because of the involvement of the aorta and its major branches in TA, coronary lesions may pose technical difficulties during CABG.

 
   References Top

1.Chawla R, Kumarvel V, Girdhar KK, Sethi AK, Bhattacharya A. Oximetry in pulseless disease. Anaesthesia 1990;45:992-3.   Back to cited text no. 1
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2.Panja M, Sarkar C, Kar AK, Kumar S, Mazumder B, Roy S, et al. Coronary artery lesions in Takayasu's arteritis-clinical and angiographic study. J Assoc Physicians India 1998;46:678-81.   Back to cited text no. 2
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3.Kathirvel S, Chavan S, Arya VK, Rehman I, Babu V, Malhotra N, et al. Anesthetic management of patients with Takayasu's arteritis: A case series and review. Anesth Analg 2001;93:60-5.   Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Khalaf HH, Arafah MR, Refaat AA, Ibrahim MF. Coronary artery bypass grafting for Takayasu arteritis with severe coronary, carotid, subclavian, and renal artery involvement and subsequent pregnancy. Interact Cardiovasc Thorac Surg 2006;5:153-5.   Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Meikle A, Milne B. Extreme arterial blood pressure differentials in a patient with Takayasu's arteritis. Can J Anaesth 1997;44:868-71.   Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Thorburn JR, James MF. Anaesthetic management of Takayasu's arteritis. Anaesthesia 1986;41:734-8.  Back to cited text no. 6
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Correspondence Address:
Harihar V Hegde
Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka - 580 009
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.84037

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