|Year : 2018 | Volume
| Issue : 3 | Page : 195-197
Peripheral arterial disease for aortobifemoral bypass grafting with severe postoperative complications: a case report
Ameta Nihar, Jacob Mathews, Pathak Sharmishtha, Arun Prakash
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, India
|Date of Submission||14-Feb-2017|
|Date of Acceptance||27-Sep-2017|
|Date of Web Publication||31-Aug-2018|
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune 411 040
Source of Support: None, Conflict of Interest: None
Peripheral arterial disease (PAD) is caused by atherosclerosis in the major extremity vessels. Incidence of PAD ranges from 3 to up to 20%. The most common symptom of the disease is intermittent claudication, mainly affecting the calf muscles. These patients usually present for surgeries extending from bypassing the blocked vascular segment to amputations. Successful outcome of these surgeries require a well-planned preoperative testing, controlled intraoperative environment and adequate postoperative management. We present an interesting case of a PAD patient who underwent a re-do surgery complicated by graft thrombosis, electrolyte disturbances and renal dysfunction, which, managed appropriately, resulted in best surgical outcomes.
Keywords: graft thrombosis, peripheral arterial disease, vascular surgery
|How to cite this article:|
Nihar A, Mathews J, Sharmishtha P, Prakash A. Peripheral arterial disease for aortobifemoral bypass grafting with severe postoperative complications: a case report. Res Opin Anesth Intensive Care 2018;5:195-7
|How to cite this URL:|
Nihar A, Mathews J, Sharmishtha P, Prakash A. Peripheral arterial disease for aortobifemoral bypass grafting with severe postoperative complications: a case report. Res Opin Anesth Intensive Care [serial online] 2018 [cited 2019 Apr 24];5:195-7. Available from: http://www.roaic.eg.net/text.asp?2018/5/3/195/240272
| Introduction|| |
Peripheral arterial disease (PAD) refers to chronic or acute syndromes caused by inadequate blood flow to the limbs . Incidence of PAD is 3–10% and increases to 15–20% in persons over 70 years of age ,,. The symptomatology ranges from intermittent claudication to gangrene of the affected part.
Anesthetic implications for a patient undergoing limb revascularization are manifold; foremost among them being the increased risk of myocardial ischemia . These patients are unable to perform the exercise stress testing and this complicates the situation. Success of these surgeries requires a well-planned preoperative testing, controlled intraoperative environment and postoperative monitoring.
We present an interesting case of PAD who underwent surgery complicated by graft thrombosis after a previous surgery, electrolyte disturbances and renal dysfunction, which, managed appropriately, resulted in best surgical outcomes.
| Case report|| |
A 53-year-old man, a known diabetic and hypertensive (well controlled on oral medications), presented with complaints of intermittent claudication since last 5 years. The patient was started on medical management and was advised to quit smoking. Subsequently, the patient developed a nonhealing ulcer about 1×1 cm in size on the right leg. Further evaluation with Doppler studies and computed tomography angiography suggested significant bilateral long-segment aorto-iliac and right infra-popliteal occlusive disease. The patient was worked up for an aortobifemoral bypass graft.
The patient had a BMI of 27 kg/m2. Considering that these patients are at higher risk of developing coronary artery disease , and the patients’ state of inactivity, a preoperative two-dimensional echocardiography was performed which revealed concentric left ventricular hypertrophy and diastolic dysfunction with normal ejection fraction. Pulmonary function tests suggested a moderate restrictive pattern (forced expiratory volume in the first 1 s/forced vital capacity: 78.26%).
General anaesthesia along with epidural analgesia and invasive monitoring was chosen as the plan of anaesthesia for the surgery. The patient was accepted under the American Society of Anesthesiologists-Physical Status II for hypertension, type-2 diabetes mellitus and restrictive lung disease. The patient was kept fasting for 6 h preoperatively, and was administered the morning dose of Tab ramipril. The morning dose of Tab metformin was skipped.
The epidural catheter was placed the level of L1–L2 intervertebral space. He was then premedicated with midazolam 1.5 mg and fentanyl 100 mcg, intravenously. Intubation was done using propofol 180 mg (divided doses) and vecuronium 7 mg, intravenously. The anaesthesia was maintained using isoflurane and a combination of nitrous oxide and oxygen.
After induction, right internal jugular vein was cannulated using a 7.5 F triple lumen catheter. Left radial artery was cannulated for arterial pressure monitoring.
The surgical procedure included clamping of the aorta for ∼1 h (with intermittent release). The surges in blood pressure during this period were managed with nitroglycerine infusion at 4 mcg/min. Intraoperatively patient was administered 4000 ml of crystalloids. For the maintenance of anticoagulation, the patient was also administered heparin 7000 IU. The duration of surgery was 7 h and involved fluid shifts; hence, it was decided against reversal and extubation at the end. The patient was shifted to the ICU for elective mechanical ventilation and hemodynamic monitoring.
The patient was evaluated three hours after the surgery using a color Doppler computed tomography angiography which showed graft thrombosis. The patient was planned to be taken up for graft thrombectomy the next day.
Issues relevant to the anesthetic management for the second surgery were hyperkalemia (serum K+ values ranging from 6.4 to 7.0 mEq/l), acute kidney injury (serum creatinine 1.8 mg/dl) and increased requirement of anticoagulation with epidural catheter in situ.
Hyperkalemia was managed with preoperative calcium gluconate intravenously, salbutamol nebulization and insulin–dextrose infusion. Surgery was performed under general anaesthesia with invasive monitoring. Intraoperative hypotension was managed with boluses of phenylephrine 50 mcg intravenously. To prevent any further graft thrombosis, heparin 5000 IU bolus, followed by infusion was administered. The patient was also given two units of fresh frozen plasma during this surgery. Postoperatively the patient was shifted back to the ICU for elective mechanical ventilation and hemodynamic monitoring.
The heparin infusion was continued in the ICU. The patient was extubated the next day after ensuring stable hemodynamics and all lab investigations including renal functions and electrolytes normalized. Epidural infusion of bupivacaine 0.125% at 4 ml/h was continued. The international normalized ratio was being measured serially. After three days of receiving heparin infusion the patient was shifted to a maintenance dose of heparin subcutaneously. The epidural catheter was removed on the fifth postoperative day. The international normalized ratio values at this time were below 1.50.
| Discussion|| |
The majority of patients with PAD have limited walking ability and this is associated with reduced physical functioning. The classical symptom in PAD is intermittent claudication (to limp), which is muscle discomfort in the lower limb produced by exercise and relieved by rest within 10 min. The symptoms are most commonly localized to the calf, but may also affect the thigh or buttocks.
PAD is caused by atherosclerosis in the major vessels supplying the extremities. Patients with intermittent claudication have normal blood flow at rest and, hence, no symptoms at rest. With exercise, occlusive lesions limit the increase in blood flow and this is associated with claudications. Acquired metabolic abnormalities in the muscle also contribute to the reduced exercise performance in PAD .
Aortic cross-clamping is a major step in the surgery and considering that these patients are per se at increased risk of myocardial events pose a great anesthetic challenge. Distal occlusion of the abdominal aorta induces an increased impedance to ejection. As the mechanisms that control the autoregulation of cardiac output and the circulatory reflexes are damped by anaesthesia, the increase in resistance is not followed by an increase in contractility or vascular tone and thus the cardiac output falls . Nitroglycerine has shown to maintain the peripheral blood flow and hemodynamics in such situations . For timely reaction to changing parameters, invasive monitoring is appropriate in these cases.
Epidural analgesia is considered as the most suitable pain relief modality in patients with PAD. Profound changes in the hemodynamic parameters as a result of pain may threaten the graft in place. However, appropriate management of epidural catheter is important as these patients are on anticoagulation in the perioperative period. An epidural catheter can be placed in the patients undergoing surgery requiring the administration of anticoagulation intraoperatively, provided that the time interval between the placement of the catheter and the administration of unfractionated heparin is at least 1 h. The removal of the catheter was a significant challenge as the patient was continuously receiving unfractionated heparin infusion. The catheter was removed once the patient was shifted to a maintenance dose of low molecular weight heparin. He was still followed up till the time of discharge for any epidural-related complications .
The other important aspect in this case was the issue of hyperkalemia before the second surgery. Hyperkalemia may have been developed due to ongoing tissue ischemia resulting from graft thrombosis. Though hyperkalemia per se may cause increased chances of dysrhythmias, still the actual incidence of dysrhythmias in the perioperative period is almost negligible . Vigilant postoperative monitoring with serial biochemical levels helps in preventing adverse outcomes due to hyperkalemia. Our patient did not have any ECG changes and thus it again was in favor of acceptance for surgery.
This case brings forward the challenges faced by anesthesiologist in the form of hemodynamic management in a vascular surgery with aortic clamping, epidural pain management in an anticoagulated patient and conduction of surgery in the background of hyperkalemia.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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