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Endovascular Repair of a Descending Aortic Aneurysm in a Pregnant Patient and Subsequent Cesarean Delivery
Abstract Number: S-23
Abstract Type: Case Report/Case Series
A 37 year old G3P2002 presented with chest pain and back pain at 22 weeks gestation. MRI showed a 5.1 cm thoracic aortic pseudoaneurysm distal to the left subclavian artery, as well as dilation of the ascending aorta and main pulmonary artery.
The patient insisted on continuing her pregnancy and agreed to proceed with endovascular repair of the aneurysm. A multidisciplinary meeting to plan the repair included an obstetrician, cardiac anesthesiologist, and cardiothoracic and vascular surgeons.
In addition to standard ASA monitors, an arterial line and central line were placed. General anesthesia was induced with propofol and rocuronium. Blood pressure was controlled intraoperatively with nicardipine and labetalol. A total of 10,000 units of heparin were given for anticoagulation. Intravascular ultrasound (IVUS) was utilized to identify the origin of the left subclavian artery, as well as measure the aorta for endograft sizing. The endovascular stent was deployed just distal to left subclavian artery. IVUS, TEE, and spot fluoroscopy were utilized to confirm adequate deployment and apposition of the thoracic endograft. No contrast was used and total radiation exposure was 8mGy.
The patient was extubated, monitored postoperatively in the ICU, and had an uneventful hospital course. Postoperative fetal monitoring was normal. At 34 weeks gestation, she was scheduled for a primary cesarean delivery. A multidisciplinary meeting for her delivery management included her obstetrician, obstetric anesthesiologists, cardiac anesthesiologists, and a cardiothoracic surgeon. Low-dose combined spinal-epidural anesthesia was elected to avoid hemodynamic changes that could occur during general anesthesia for cesarean delivery (rapid sequence induction, intubation, emergence). Cesarean delivery and her postoperative course were uneventful.
Presentation of descending aortic aneurysm is rare during pregnancy. Etiologies include hypertension, hypercholesterolemia, atherosclerosis, connective tissue abnormalities, trauma, and inflammatory and infectious disorders.1 Dissection during pregnancy occurs most often in the third trimester or early postpartum period due to maximal increases in cardiac output.2 Multidisciplinary management for aneurysm repair and for delivery is essential. Endovascular repair during pregnancy is challenging due to limitations on use of IV contrast, CT, X-rays and fluoroscopy. Utilization of intraoperative TEE and IVUS allowed avoidance of contrast and minimization of ionizing radiation. Epidural anesthesia has been used successfully for cesarean delivery to minimize hemodynamic changes that increase sheer stress during intubation and emergence.1,3
1. Lebak K, et al. Int Anesthesiol Clin. 2011;49:81-7.
2. Child AH. In: Oakley C. London: BMA publication;1997:153-62.
3. Saeki N, et al. J Anesth. 2010;24:277-9.