DP12: ANESTHETIC MANAGEMENT OF GRADE IV AORTIC RUPTURE WITH PSEUDOANEURYSM IN A CRITICALLY ILL PATIENT WITH LOW EJECTION FRACTION
Alexander A Haddad, DO; Sounak Roy, MD; Mihir Desai, DO; Kerri M Lydon, MD; Edward K McGough, MD
University of Florida - Jacksonville
Introduction/Background: Blunt thoracic aortic injury (BTAI) is a life-threatening condition often caused by high-impact trauma like motor vehicle collisions (MVCs). Grade IV aortic rupture with pseudoaneurysm presents significant anesthetic challenges, especially in patients with complex cardiovascular histories. The rise of endovascular techniques such as thoracic endovascular aortic repair (TEVAR) has been pivotal in reducing mortality [1]. Anesthetic management must optimize hemodynamics, reverse anticoagulation, and minimize blood loss while preventing paraplegia, a feared complication in TEVAR cases [1]. This report highlights the importance of anesthetic management in ensuring favorable outcomes.
Methods: A male in his 60s with atrial fibrillation on rivaroxaban, prior coronary artery bypass graft (CABG), heart failure with ejection fraction (EF) 30-35%, and hypertension presented after an MVC. He was hypotensive with mean arterial pressures (MAP) in the 50s, and imaging revealed a Grade IV aortic rupture with pseudoaneurysm. The patient was stabilized with prothrombin complex concentrate for anticoagulation reversal, activation of the massive transfusion protocol (MTP), and blood pressure control using clevidipine and esmolol drips. TEVAR was chosen due to his poor EF, but intraoperative complications required a surgical cutdown of the common femoral artery (CFA). The anesthetic approach focused on maintaining perfusion pressures and preventing neurologic complications [2].
Results: The patient was admitted to the surgical intensive care unit (SICU) intubated and on vasopressors. Over two days, his hemodynamics stabilized, allowing for extubation with marked respiratory improvements. He underwent a video-assisted thoracoscopic surgery (VATS) for related complications and was readmitted to the SICU. After a stable recovery, he was discharged one week later in good condition, demonstrating significant improvement.
Discussion/Conclusion: This case highlights the pivotal role anesthesiologists play in managing trauma patients with complex cardiovascular profiles. Anticoagulation reversal with prothrombin complex concentrate was crucial, especially with the lower thrombotic risk in atrial fibrillation compared to mechanical valves. Intraoperative management prioritized spinal cord perfusion and MAP control, essential for preventing spinal cord ischemia [1].
Postoperatively, careful consideration was given to the timing of anticoagulation resumption, weighing a heparin bridge versus restarting rivaroxaban. The increasing use of endovascular techniques for aortic injuries offers opportunities to optimize anesthetic interventions [2]. This case illustrates how personalized anesthetic strategies lead to favorable outcomes in high-risk trauma scenarios.
References:
1. Cheruku S, Huang N, Meinhardt K, et al. Anesthetic Management for Endovascular Repair of the Thoracic Aorta. Anesthesiol Clin. 2019;37 (4):593-607.
2. Ellard L, Djaiani G. Anaesthesia for vascular emergencies. Anaesthesia. 2013;68(Suppl1):72-83.