A 37 year old G3P2002 presented with chest pain and back pain at 22 weeks gestation. MRI showed a 5.1 cm thoracic aortic pseudoaneurysm distal to the left subclavian artery, as well as dilation of the ascending aorta and main pulmonary artery.
The patient insisted on continuing her pregnancy and agreed to proceed with endovascular repair of the aneurysm. A multidisciplinary meeting to plan the repair included an obstetrician, cardiac anesthesiologist, and cardiothoracic and vascular surgeons.
In addition to standard ASA monitors, an arterial line and central line were placed. General anesthesia was induced with propofol and rocuronium. Blood pressure was controlled intraoperatively with nicardipine and labetalol. A total of 10,000 units of heparin were given for anticoagulation. Intravascular ultrasound (IVUS) was utilized to identify the origin of the left subclavian artery, as well as measure the aorta for endograft sizing. The endovascular stent was deployed just distal to left subclavian artery. IVUS, TEE, and spot fluoroscopy were utilized to confirm adequate deployment and apposition of the thoracic endograft. No contrast was used and total radiation exposure was 8mGy.
The patient was extubated, monitored postoperatively in the ICU, and had an uneventful hospital course. Postoperative fetal monitoring was normal. At 34 weeks gestation, she was scheduled for a primary cesarean delivery. A multidisciplinary meeting for her delivery management included her obstetrician, obstetric anesthesiologists, cardiac anesthesiologists, and a cardiothoracic surgeon. Low-dose combined spinal-epidural anesthesia was elected to avoid hemodynamic changes that could occur during general anesthesia for cesarean delivery (rapid sequence induction, intubation, emergence). Cesarean delivery and her postoperative course were uneventful.
1. Lebak K, et al. Int Anesthesiol Clin. 2011;49:81-7.
2. Child AH. In: Oakley C. London: BMA publication;1997:153-62.
3. Saeki N, et al. J Anesth. 2010;24:277-9.