Difficult Vascular Case ... for Tomorrow

[inflamesdjk02]

74 y/o M brought in by EMS with syncope, hypotension. FOUND TO HAVE AN 11 X 13 CM INFRARENAL AAA!!! The catch ... also found to have critical AS with a peak gradient of 85 mmHg and an AVA of 0.75 cm2 with a BNP of > 6000 and EF of 50%, "recently placed on home oxygen 2 L NC". The patient was discharged from another regional hospital because "the vascular surgeon refused to operate". The patient was admitted to Hospice and told that death would be imminent secondary to ruptured AAA, however, after 4 days at home, the patient called our hospital and is now an inpatient scheduled for open AAA repair tomorrow - and I'm on call...

Plan? I already requested sterile holy water and an intraoperative priest ...

Only in Florida ...

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[Urzuz]

I hope they consulted a cardiologist and have been working to optimize his volume status before tomorrow. If he has any signs of failure (rales, edema, etc) the case gets postponed or punted to one of my more cavalier partners if they would be willing to do it.

In any event, I think you'll get him through this as long as the surgeon doesn't screw his part of the operation up royally. There are a number of ways to accomplish the same goal, but this is what I would do:

Put an awake arterial line in. Induce with drug of choice (propofol, etomidate, whatever), but be prepared to preemptively counteract the vasodilatory effects of whatever drug you give with small boluses phenylephrine (don't slam in 500 mcg willy nilly without first seeing how he responds to 100 mcg). For volume/central access, I would probably put in a 8.5 or 9 Fr introducer with a DLIC through the introducer port. I would run the anesthetic a little on the lighter side (eg: 0.7 MAC) and have a phenylephrine infusion running while your hands are tied up with the central line.

From that point on it's pretty much like any other infrarenal AAA, just being cautious since the dude has bad AS. Have phenylephrine and/or norepinephrine ready. Have nitroglycerin ready as well, though I wouldn't expect major hemodynamic changes with an infrarenal clamp (plus, the afterload the heart sees shouldn't increase all that much since his AVA is 0.75 cm2 already. If you do need to give a vasodilator, once again, be very judicious with it and go slowly). Don't flood the dude with crystalloid, and give blood early (don't get behind). Be ready to give blood quickly. Check ABGs regularly to make sure you're not falling behind. If you're adept at TEE, you can drop one (but I don't think it is necessary). When the clamp is coming off, maybe hit him with a small dose of epinephrine (10-20 mcg) just to stave off bad spirits. Maybe even tell the surgeon to do a partial release to see how the patient responds before fully taking it off. I would probably take him to the ICU intubated unless the whole case was smoother than a baby's behind and I couldn't even make up a reason to leave him intubated...and usually I am pretty aggressive with extubating patients at the end of cases.

You'll do great, and so will the patient.

 

[narcusprince]

I will let some pre-board certified ca3 chime in on how to do the case. But I will say this both can be fixed at the same time. I have seen it done at the cleveland clinic. A more advanced questiom is given his cva status would you place a spinal drain and fully anticoagulate for cpb?

 

[Urzuz]

I will let some pre-board certified ca3 chime in on how to do the case. But I will say this both can be fixed at the same time. I have seen it done at the cleveland clinic. A more advanced questiom is given his cva status would you place a spinal drain and fully anticoagulate for cpb?

That's mean! He isn't posting this clinical case to generate discussion among the residents...he is looking for guidance since he has to do it tomorrow!

 

[Spinach Dip]

Plan? I already requested sterile holy water and an intraoperative priest ...

You might want to have a rabbi and an imam on call...y'know...just in case.

 

[PainDrain]

I will keep this brief. He should have both the valve and the AAA fixed simultaneously or staged in the same anesthetic.

Pre-op: CMP, Cbc, coags, type/cross for a 4 units/4FFP/PLTs, echo already done, EKG, CXR.
Induction: Awake A-line, two large bore IVs, midaz for preop jitters, narcotic induction with fentanyl and maybe a small amount of propofol. Post-induction place a cordis sheath and a CVC- cordis sheath for volume and Triple lumen for drips. Have epi, nitro, phenylephrine on hand and in drips on pumps. Maintain with a low level of gas, sufentanyl and midaz infusions. Would opt for fixing the valve first followed by the AAA because his heart isn't likely to handle the pressure changes of cross clamping/unclamping with critical AS and a heart currently in failure.

 

[itwasalladream]

If you have the facilities to do a staged or combined procedure - I agree with the suggestions to fix the AV. Severe AS with heart failure has the worst life expectancy, around 1 yr. Consider advocating for that. Does he have a cath? Good chance of CAD as well. At the very least, he could be optimized further by cardiology before undergoing the surgery.

If the case moves forward as scheduled: Awake a-line. Cardio-stable induction of choice. Consider having a phenylephrine drip going, started before your slow induction, with esmolol or nitroglycerin around to bolus if the pressure/HR gets too high. Inhaled inductions are nice and hemodynamically smooth too, if you're comfortable with them. Large bore PIVs (or a RIC), and IJ cordis. Personal preference, but I would put a swan in especially for the ICU care. Drop a TEE, even if you're not super familiar with it, you can get a better handle on volume status. Stay ahead on volume - maybe not the patient to get carried away with "restrictive transfusion" strategy. A little bit of fluid overload can be diuresed in the unit, and can be avoided with monitoring on TEE. I'd expect him to stay intubated. Can do a low level gas anesthetic, with paralytic and maybe a Bis to help out. Keep the pressure up at unclamping. I bet the heart handles the clamp going on without issue.
Good luck, I bet he does fine. Maybe gets a TAVR (or open AVR?) down the road...

 

[Docuronium]

I will keep this brief. He should have both the valve and the AAA fixed simultaneously or staged in the same anesthetic.

Pre-op: CMP, Cbc, coags, type/cross for a 4 units/4FFP/PLTs, echo already done, EKG, CXR.
Induction: Awake A-line, two large bore IVs, midaz for preop jitters, narcotic induction with fentanyl and maybe a small amount of propofol. Post-induction place a cordis sheath and a CVC- cordis sheath for volume and Triple lumen for drips. Have epi, nitro, phenylephrine on hand and in drips on pumps. Maintain with a low level of gas, sufentanyl and midaz infusions. Would opt for fixing the valve first followed by the AAA because his heart isn't likely to handle the pressure changes of cross clamping/unclamping with critical AS and a heart currently in failure.

Same--and have the phenyl in line to start.

 

[boujieboujie]

Agree with above. While i do believe this case can be done safely with the AS, if a staged procedure is to be done, I would suggest a trans-apical TAVR to avoid a pump run.

 

[Planktonmd]

You must be at the university hospital where this kind of cases usually ends... if you are not then that would be your next step, send him to a place where people like this stuff.
If you have to do it then there is a distinct chance he will not handle aortic cross clamping very well no matter what you do, so fixing the valve then fixing the aneurysm is probably the only logical solution. Although I have to say people do get away with crazy things all the time, do you feel lucky?

 

[IlDestriero]

Count me in on the side of his heart not tolerating the cross clamp. Good luck.

 

[DrBeaker]

Transapical vs transcaval TAVR. I would want to know diastolic function. AS with pseudonormal LV filling is a different beast from when they only have impaired relaxation.

 

[OB1🤙]

I'm late to this party but I would have cards attempt a balloon valvuloplasty from a brachial site prior to the AAA repair. That should be relatively straightforward, assuming they can cross the valve.

 

[Cytarabine]

I don't know the criteria for endovascular stenting - why wouldn't that be the go to here?

 

[Ezekiel2517]

If you proceed with open AAA, it's not too complicated as far your plan. Good points mentioned above. Much more important is how good the surgeon is. Because if he's not, this patient is toast, regardless of what you do.

 

[IlDestriero]

If you proceed with open AAA, it's not too complicated as far your plan. Good points mentioned above. Much more important is how good the surgeon is. Because if he's not, this patient is toast, regardless of what you do.

That's point I emphasize with the fellows when they tell me about their big money offer from some smaller hospital in a tiny city in flyover no man's land that seems to offer "full service". That's great, but are the surgeons any good. That makes all the difference. During my .mil time I saw some hacks and when I did my rural .mil gig the surgeons at the other area hospital where I could have moonlighted and made some good loot were notoriously bad. Maybe that is how rural CRNAs can hide bad outcomes. The surgeon is so bad, nobody notices the shady anesthetic.

 

[Spinach Dip]

That's point I emphasize with the fellows when they tell me about their big money offer from some smaller hospital in a tiny city in flyover no man's land that seems to offer "full service". That's great, but are the surgeons any good. That makes all the difference. During my .mil time I saw some hacks and when I did my rural .mil gig the surgeons at the other area hospital where I could have moonlighted and made some good loot were notoriously bad. Maybe that is how rural CRNAs can hide bad outcomes. The surgeon is so bad, nobody notices the shady anesthetic.

Bad surgeon. Bad anesthetist. In the same room.... That is a truly frightening thought.

 

[vector2]

Put pads on. 4 units prbc in the room. Awake a-line. Cardiac induction du jour. Have epi, norepi hanging. Double stick Cordis + 12fr TLC. Drop TEE probe. Do a transapical TAVR. Fix AAA.

 

[deleted162650]

Bad surgeon. Bad anesthetist. In the same room.... That is a truly frightening thought.

A good surgeon deserves a good anesthesiologist. A bad surgeon NEEDS one.

 

[pgg]

So how'd it go?

 

[B-Bone]

So how'd it go?

Perhaps it's still going on...

 

[ecCA1]

Place the central line prior to induction. Local, touch of versed and slick hands are all you need here. Trying to manage hemodynamics while scrubbed into the line is risky unless you have a skilled assistant.

 

[chocomorsel]

We used to do all our lines for vascular and heart cases at the VA in residency awake. Yup, just a little local and reassurance. 9FR.

 

[deleted171991]

We used to do all our lines for vascular and heart cases at the VA in residency awake. Yup, just a little local and reassurance. 9FR.

They still do that in ICUs.

 

[McPoyle]

I don't know the criteria for endovascular stenting - why wouldn't that be the go to here?

This is my question as well, otherwise agree with others. Arterial line, slow gentle induction, introducer, probe. TAVR then AAA.

 

[OB1🤙]

For those suggesting TAVR-it's a nice thought but the workup required for one is probably prohibitive for this case. You need TEE, CTA, need to figure out the coronary heights, etc. You don't just bang them in on a day's notice.

 

[ecCA1]

What if there was no provision for TAVR? Not great with his AV but I think you could get away with endo repair, possibly even open if surgeon is good and doesn't treat it as a "teaching case."