Ain-Shams Journal of Anaesthesiology

CASE REPORT
Year
: 2015  |  Volume : 8  |  Issue : 4  |  Page : 681--682

Anesthetic considerations in a patient with Takayasu's arteritis for cesarean section


S Ghodki Poonam, D Harnagle Kalpana 
 Department of Anaesthesiology, Shrimati Kashibai Navale Medical College, Pune, Maharashtra, India

Correspondence Address:
S Ghodki Poonam
Department of Anaesthesiology, Shrimati Kashibai Navale Medical College, Pune 411041, Maharashtra
India

Abstract

Takayasu«SQ»s arteritis (TA), also known as pulseless disease, is a rare disease involving the aorta and its main branches. Anesthesia for cesarean section in patients with TA is complicated by associated hypertension, end organ dysfunction, stenosis of major blood vessels, and overall vasculopathy. We report a pregnant patient with TA with common carotid artery involvement with a history of two abortions. She had also undergone bilateral renal artery angioplasty for stenosis. We discuss the anesthetic considerations with emphasis on appropriate monitoring for a favorable outcome in pregnancy complicated with TA.



How to cite this article:
Poonam S G, Kalpana D H. Anesthetic considerations in a patient with Takayasu's arteritis for cesarean section .Ain-Shams J Anaesthesiol 2015;8:681-682


How to cite this URL:
Poonam S G, Kalpana D H. Anesthetic considerations in a patient with Takayasu's arteritis for cesarean section . Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2021 Dec 5 ];8:681-682
Available from: http://www.asja.eg.net/text.asp?2015/8/4/681/172769


Full Text

 Introduction



We report a case of a 25-year-old full-term patient (G3P0L0A2; gravida 3, abortions 2), a known case of Takayasu's arteritis (TA), with operated bilateral renal artery stenosis admitted at our institute at 36 weeks for safe confinement. She had a history of convulsions and syncopal attacks 5 years ago when she was diagnosed with hypertension. Further evaluation revealed right common carotid artery stenosis, which was confirmed by color Doppler as TA, with carotid artery thrombosis and bilateral renal artery stenosis. She underwent real balloon angioplasty bilaterally 5 years ago and was started on 75 mg ecosprin and 2.5 mg amlodipine oral tablets. The other significant past history was that of pulmonary tuberculosis during childhood for which she had received a complete antitubercular course.

On admission, she gave a history of dyspnea on exertion (NYHA grade II) and weakness in the right upper limb. Clinical examination revealed a blood pressure of 160/100 mmHg in the left upper limb; right upper limb pulses were absent and bilateral lower limb pulses were well felt. She was started on prednisolone at 40 mg/kg, 20 mg nicardia, and 40 mg isoxsuprine; ecosprin and amlodipine were continued. A 2D echocardiography was performed, which showed normal results, with an ejection fraction of 60%. Color Doppler revealed completely occluded carotid artery with no identification of the right common carotid and right internal carotid arteries. Other laboratory investigations, arterial blood gases, and ECG were normal. An elective lower-segment cesarean section was planned at 37 weeks in view of the high-risk pregnancy. The patient did not give consent for any form of regional anesthesia, and hence general anesthesia was planned. Central venous access through the right cephalic vein was introduced preoperatively to monitor the central venous pressure (CVP). Baseline parameters were normal inside the operation theater; blood pressure was controlled with a reading of 140/90 mmHg. The patient was intubated after rapid sequence induction (thiopentone and succinylcholine), and anesthesia was maintained with nitrous oxide and oxygen mixture with intermittent isoflurane and vecuronium topups. Intravenous xylocard 2% 60 mg was given to attenuate laryngoscopy response. A 2.8 kg baby with an Apgar score of 7 was delivered, following which midazolam and fentanyl were given. Surgery was completed uneventfully and the patient was extubated after reversal with neostigmine. Intraoperative monitoring included ECG, capnograph, bispectral index, heart rate, blood pressure, CVP, saturation, and urine output. All vitals were maintained well. Postoperative recovery of the patient was unremarkable.

 Discussion



TA is a chronic inflammatory disease of unknown etiology of the aorta and its major branches. It results in narrowing of the arterial lumen with consequent distal ischemia and loss of pulse distal to the site of the lesion, hence the term 'pulseless disease' [1] . The exact pathology of TA is unknown; however, tuberculosis, streptococcal infections, and rheumatoid arthritis have been debated as the etiological factors. Our patient did have a history of tuberculosis. Regardless of the etiology, steroids are the mainstay of treatment in the management of TA. Patients also need antihypertensive therapy (hypertension is generally of renovascular origin) and antiplatelets because of the propensity of thrombus formation. Our patient was started on all of the recommended drugs [2] . TA is more common in young females, accounting for almost 80% of the total reported cases. The course of the disease is unaltered in pregnancy; however, one has to be careful about the peripartum conduction of these patients as they are prone to develop complications such as hypertension, multiple organ dysfunction, hampered regional blood flow, and intrauterine growth restriction [3] . There are four types of TA depending on the level of aortic involvement [1],[2] . Our patient belonged to type I with involvement of the common carotid with associated renal artery stenosis. She had hypertension, which is a known accompaniment in TA; hence, monitoring blood pressure plays a pivotal role in TA patients. However, we used only a noninvasive method of blood pressure monitoring to avoid inflicting trauma during arterial cannulation to already diseased vessels. Our patient had good radial pulsations on the left hand, and therefore noninvasive blood pressure monitoring was equally reliable [4] . Although the use of a pulmonary artery catheter is recommended, we assume that CVP measurements provided adequate information about cardiac preload in our patient with normal 2D echo findings. Nevertheless, a normal CVP value does not ensure adequate cerebral blood flow with vasculopathy, especially in this patient with carotid artery stenosis [4] .

The debate between the choices of anesthesia still continues. Regional anesthesia has widespread application, but the sympathetic blockade and hypotension associated with a central neuraxial block may be hazardous to patients with an already compromised regional blood flow due to stenosed vessels [5] . General anesthesia has its own merits and demerits. It avoids hypotension seen with regional anesthesia, but one has to be careful to avoid sudden increases in blood pressure as during laryngoscopy, as this can lead to cerebral hemorrhage or myocardial infarction. The major advantage of regional anesthesia in such patients is that it allows monitoring of brain perfusion through the patient's level of consciousness, which is lost in general anesthesia [6] . Hence, an epidural anesthesia with slow installation of blockade may be preferred in suitable patients. Because of lack of consent, we had only general anesthesia as the choice. Neurologic monitoring is of paramount importance while providing general anesthesia in patients with TA and common carotid artery involvement [7] . We could not monitor for cerebrovascular insufficiency in this case because of lack of infrastructure.

 Conclusion



TA in pregnancy has a favorable outcome and any technique of anesthesia that reduces the complication rate should be implemented. Special attention should be given to maintain the blood pressure and fluid status of the patient.

 Acknowledgements



Conflicts of interest

There are no conflicts of interest.

References

1Stoelting RK, Dierdorf SF. Anaesthesia and co-existing disease. 4th ed. New York: Churchill Livingstone; 2002.
2Kerr GS, Hallahan CW, Giordono J, et al. Takayasu's arteritis. Ann Intern Med 1994; 120:919-929.
3Hawth JC, Cunnigham FG, Young BK. Takayasu's syndrome in pregnancy. Obstet Gynecol 1977; 50:373-375.
4Meikle A, Milne B. Extreme arterial blood pressure differentials in a patient with Takayasu's arteritis. Can J Anaesth 1997; 44:868-871.
5Henderson K, Fludder P. Epidural anaesthesia for caesarean section in a patient with severe Takayasu's disease. Br J Anaesth 1999; 83:956-959.
6Ramanathan S, Gupta U, et al. Anaesthetic consideration in Takayasu's arteritis. Anesth Analg 1979; 58:247-249.
7Hung N, et al. Severe Takayasu's arteritis in pregnancy: the role of central haemodynamic monitoring. Am J Obstet Gynecol 1988; 159:1135-1136.