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Anesthetic Management of Parturient with Type 1 Endovascular leak after TEVAR
Abstract Number: RF6AI-344
Abstract Type: Case Report Case Series
A 28yo G4P3013 presented with precordial pain and palpitations at 12 weeks gestation. She had a history of repair of Type A Aortic Dissection distal to the aortic root extending to the level of the iliac bifurcation and a 6.5 cm aneurysm of the ascending aorta, a year prior to this presentation. During this admission, a CT angiography of the chest revealed increase in the aneurysmal dilation of the distal aortic arch, consistent with a type B descending thoracic aortic aneurysm. She underwent a Thoracic EndoVascular Aortic Repair (TEVAR) with a carotid-subclavian artery bypass and discharged home. During early third trimester, the patient re-presented with chest pain and Type 1 Endoleak of the graft was detected. Cardiac Surgeons evaluated the patient and discharged her home as the vital signs and serial CT-Scans were stable. A multidisciplinary team was convened to plan delivering the fetus at 35weeks gestation via cesarean section to prevent worsening of 1B Endoleak consequent to hemodynamic stress and strain of labor and delivery. Her other medical history was significant for hypothyroidism as a result of thyroidectomy and a central line associated deep venous thrombosis requiring anticoagulation.
For elective cesarean delivery, pre-induction arterial catheter and large-bore intravenous catheters were placed. Combined Spinal-Epidural neuraxial technique was used, after ensuring appropriate anticoagulation timing, with 10mg of Isobaric Bupivacaine, 10mcg of fentanyl, 200mcg of preservative free morphine as the spinal dose. Transient hypotension after induction of spinal anesthesia was normalized using titrated boluses of phenylephrine. Esmolol infusion was used as adjuvant to control contractility and blood pressure in the intraoperative and immediate postoperative period. Patient remained hemodynamically stable and delivered a healthy neonate. Subsequent course of the patient was unremarkable and was discharged home on postoperative day three.
Anesthetic goals for this parturient with endovascular leak include avoiding fluctuation in blood pressure so that the transmural pressure does not increase, while maintaining adequate feto-placental and coronary perfusion. This criteria should be strictly adhered to during entire perioperative period. The obstetricians should be gentle in delivering the baby with vacuum assist as deemed necessary. Cardiovascular surgeons should be available on site if complications arise due to vascular disruption.