Volume 2 - Issue 4

Anaesthetic management of patients with Takayasu arteritis

Dr. Vasanthi Vidyasagaran

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence:  Vasanthi.vidyasagaran@gmail.com

A 30-year-old woman presented to the assessment clinic for pre-anaesthetic evaluation. She was to have abdominoperineal resection for rectal malignant tumour.

On eliciting drug and allergy history, she mentioned that she frequently experienced severe headache, for which she took medications, the details of which were not available, and it was presumed to be migraine. She did not give history of any other major medical illness.

She looked very emaciated and weighed 30 kg. She also gave a history of not being able to take normal diet. On examination, the first finding to be noted was an absent radial pulse. No diagnosis was made at that instance. She was subsequently hydrated with intravenous fluids and reassessed. While the radial, brachial and superficial temporal pulses were still not palpable, pulse in her Dorsalis Pedis artery was felt. Blood pressure could not be recorded. Systemic examination did not reveal any other abnormality.

All investigations including chest X-ray and echocardiogram were normal, with no evidence of pulmonary hypertension or left ventricular failure. Routine blood investigations like urea and random sugar were normal. Haemoglobin was 10 g/dl. Her coagulation profile was within normal limits, ESR was elevated at 120 mm/h.

A diagnosis of arteritis was then considered, and she was referred to the vascular department. After further investigations, including CT, MRI, and angiography, it was confirmed to be a case of Takayasu's arteritis. Liver function tests were done once the diagnosis was made, and they were normal.

Our choice of anaesthesia was epidural combined with general anaesthesia.

Discussion

Takayasu's arteritis is a rare, progressive pan endarteritis involving the aorta and its main branches, and successful anaesthetic management of these patients is a challenge.

The anaesthetic concerns in this situation include:

  • Uncontrolled hypertension and end organ dysfunction due to stenosis of major blood vessels.
  • Difficulty in monitoring blood pressure in the upper limbs, necessitating lower limb NIBP, with periodic checking the dorsalis pedis arterial pulse bilaterally in Lloyd Davies position. IBP can be monitored from the posterior tibial artery if required, but better avoided to prevent damage to the existing normal vessels.
    • Doppler ultrasound may be used to identify artery for measuring blood pressure.
    • Blood pressure recording from occluded vessels may under-read blood pressure, leading to inappropriate use of vasopressors. This will lead to iatrogenic hypertension and subsequent adverse outcomes like headache and visual problems.
  • Maintenance of mean arterial pressure, adequate enough to maintain end organ function (cardiac, renal, cerebral). Existing arteritis adds to the challenge.
    • End organ function may be assessed with cardiac and respiratory monitoring, and urine output measurement.
  • Tight maintenance of fluid regime
    • With the presence of thrombosis of major vessels in the upper extremities, central venous access may be not an option. Peripherally inserted cardiac output monitoring may be the safe and efficient alternative to ensure appropriate fluid management.
  • Cushingoid features due to long term steroid intake, requiring perioperative supplementation.
  • Possibility of patient being on antiplatelet drugs or anticoagulants, requiring precautions prior to regional anaesthesia and surgery.
  • Potentially long surgery with major fluid shifts.

Anaesthesia for an obstetric patient with known Takayasu's arteritis

A 25-year-old primi-gravida, known case of Takayasu's disease involving the aortic arch was posted for elective caesarean section. Vessels of the upper extremity were involved in her case.

The concerns here include all those mentioned above, along with physiological changes of pregnancy to be considered during elective surgery. During preoperative assessment in the antenatal period, thorough assessment of cardiac status, renal parameters and pulmonary function were done.

Assessment of airway and spine to assess feasibility of general anaesthesia or regional anaesthesia was performed.

Both GA and RA have advantages and disadvantages. Therefore, we need to weigh risks and benefits in each patient.

In awake patients, under regional anaesthesia, monitoring cerebral circulation is possible. However, sympatholysis from subarachnoid block (SAB) may compromise end organ function.

Under general anaesthesia, hemodynamic fluctuations during intubation and extubation may cause rupture of vessels. Hence extreme caution must be exercised while anaesthetising these patients, and the whole process must be conducted in a gentle smooth manner.

Epidural anaesthesia provides good combination of an awake patient, slow onset sympathetic block and hemodynamic stability with carefully titrated top-ups. Hence, we opted to use epidural anaesthesia for this patient for LSCS, with postoperative monitoring in HDU care due to risks of vessel rupture, uncontrolled hypertension and postpartum haemorrhage.

References

  • Henderson K, Fludder P. Epidural anaesthesia for Caesarean section in a patient with severe Takayasu's disease. Br J Anaesth 1999;83(6):956-9.
  • Ramanathan S, Gupta U, Chalon J, Turndorf H. Anaesthetic consideration in Takayasu's arteritis. Anesth Analg. 1979;58:247-9.
  • Goel N, Gupta K, Wadhawan S, Suchdeva P, Anand R. Undiagnosed Takayasu arteritis: an anaesthetic challenge. J Anaesth Clin Pharmacol. 2009;25:505-06.
  • Lew E, Yeo SW, Thomas E. Combined spinal-epidural anaesthesia using epidural volume extension leads to faster motor recovery after elective caesarean delivery: a prospective, randomized, double blind study. Anesth Analg. 2004;98:810-4.
  • Blumgart CH, Ryall D, Dennison B, Thompson-Hill LM. Mechanism of extension of spinal anaesthesia by extradural injection of local anaesthetic. Br J Anaesth. 1992;69:457รขโ‚ฌโ€œ60.

Take- home lesson

Choice of anaesthesia is one of the factors which determine a successful outcome of a surgical patient.


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