P028: THE ANESTHESIOLOGIST ROLE AND CONSIDERATIONS FOR RECURRENT SUBCLAVIAN PSEUDOANEURYSM FOR LEFT CAROTID-SUBCLAVIAN BYPASS ERODING INTO THE LEFT MAIN BRONCHUS
Aaron Hacker, DO1; Elham Shams, MHS2; Keyan Shasti1; Edward Parker, DO1; 1Westside Hospital; 2Novasoutheastern University college of Osteopathic Medicine
We present the case of a 75-year-old female with a complex medical history of chronic obstructive pulmonary disease (COPD), chronic hypoxic respiratory failure, left lobe empyema status post video-assisted thoracic surgery (VATS) and decortication, who presented for thoracic endovascular repair (TEVAR) of a left subclavian artery aneurysm and left carotid subclavian bypass. The patient denied history of smoking but had been utilizing home oxygen therapy prior to weaning herself off approximately 1-2 months prior to presentation.
Preoperative assessment revealed severe hypoxemia with a partial pressure of oxygen (PaO2) of 73.70 mmHg on BiPap with FiO2 50%. Echocardiography demonstrated preserved left ventricular function and no significant valvular disease, as only mild MR and TR were noted.
The patient was scheduled for TEVAR and left carotid subclavian bypass under general anesthesia with invasive monitoring. Preoperatively, the patient received nebulized bronchodilators, intravenous methylprednisolone, and antibiotic prophylaxis. General anesthesia was induced with intravenous propofol and fentanyl and maintained with sevoflurane. Remifentanil was considered and available on an as needed basis. The patient was intubated with a left-sided double-lumen endotracheal tube for selective lung ventilation.
Intraoperative monitoring included invasive arterial blood pressure, central venous pressure,. The procedure was complicated by patient comorbidities and the potential for significant hemodynamic shifts. There were no significant intraoperative bleeding or hemodynamic changes.
Postoperatively, the patient was extubated to BiPap in the operating room and transferred to the intensive care unit (ICU) for monitoring. The patient required postoperative mechanical ventilation for 24 hours due to poor cough efforts, hypoxemia and low Sp02 in 83-86%. The patient was discharged from the ICU on postoperative day 4 and from the hospital on postoperative day 10 without any major complications.
In conclusion, this case report highlights the challenges of managing a complex patient with significant respiratory compromise undergoing TEVAR and left carotid subclavian bypass. The perioperative management of this patient required a multidisciplinary approach involving the anesthesia team, thoracic surgeons, and critical care specialists. Careful attention to preoperative optimization, intraoperative monitoring, and postoperative management can lead to successful outcomes in high-risk patients undergoing complex procedures.