2026 FSA Podium and Poster Abstracts

Introduction/Background: Complete occlusion of the innominate artery is an uncommon vascular pathology that may result in cerebral hypoperfusion, upper extremity ischemia, and marked inter-arm blood pressure discrepancy. Surgical revascularization with ascending aortic–to–common carotid artery bypass combined with carotid endarterectomy presents significant anesthetic challenges, including maintenance of adequate cerebral perfusion, reliable hemodynamic monitoring, and mitigation of perioperative stroke and myocardial infarction risk. We describe the perioperative anesthetic management of a patient undergoing ascending aortic–to–right common carotid artery bypass with concomitant right carotid endarterectomy in the setting of complete innominate artery occlusion.

Methods: A 65-year-old woman with hypertension, hyperlipidemia, and significant tobacco use presented with progressive dizziness and right-sided paresthesias. Imaging demonstrated complete right innominate artery occlusion with severe right carotid stenosis. After multidisciplinary evaluation, she underwent ascending aortic–to–right common carotid artery bypass and right carotid endarterectomy under general anesthesia. A left radial arterial line was placed for continuous blood pressure monitoring due to absent right-sided perfusion. Central venous access was obtained via the left subclavian vein under ultrasound guidance. Continuous neurophysiologic monitoring included somatosensory evoked potentials (SSEPs), electroencephalography (EEG), and cerebral oximetry. Systemic anticoagulation was achieved with heparin prior to partial aortic clamping and carotid cross-clamping. Hemodynamic goals were adjusted according to surgical stage to optimize cerebral perfusion.

Results: Intraoperatively, controlled hypotension (systolic blood pressure in the 80s mmHg) facilitated safe partial aortic clamping without changes in cerebral oximetry or neurophysiologic monitoring. During carotid clamping, systolic blood pressure was augmented to >130 mmHg using phenylephrine infusion to support cerebral perfusion. Total aortic clamp time was nine minutes. No neurologic changes were detected throughout the procedure. The patient was extubated at case completion, neurologically intact, and transferred to the intensive care unit. Postoperatively, right upper extremity blood pressure measurements normalized and were equivalent to the left arm. She remained hemodynamically stable with no new neurologic deficits.

Discussion/Conclusion: Innominate artery occlusion requiring aorto-carotid bypass with carotid endarterectomy poses unique anesthetic considerations. Profound inter-arm blood pressure discrepancy necessitates strategic arterial line placement in the unaffected limb for accurate monitoring and vasoactive titration. Avoidance of vascular access on the compromised side reduces procedural risk. Dynamic blood pressure management tailored to surgical stages—controlled hypotension during aortic clamping and permissive hypertension during carotid cross-clamping—supports myocardial and cerebral protection. Multimodal neurophysiologic monitoring enhances early detection of cerebral ischemia and guides intraoperative management. Successful outcomes in these complex reconstructions depend on meticulous hemodynamic control, vigilant neurologic monitoring, and close collaboration between anesthesiology, cardiothoracic, and vascular surgical teams.