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Nidhi Bhatia, MD, DNB*, Kiran Jangra, MD**

*Assistant Professor, **Senior Resident

Dept. of Anesthesiology & Intensive Care, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh PIN-160 012, (India).

Correspondence: Nidhi Bhatia, Assistant Professor, Dept. of Anesthesiology & Intensive Care, Postgraduate Institute of Medical Education & Research Sector-12, Chandigarh PIN-160 012, (India); Ph: +919914207483; Email: nidhi.bhatia75@gmail.com

Dear Editor,

Takayasu’s arteritis (TA) is a chronic progressive pan-endarteritis involving the aorta and its main branches, associated with stenosis of major blood vessels, severe uncontrolled hypertension and end-organ dysfunction, making its perioperative management very challenging for the anesthesiologist.

A 28 years old severely preeclamptic, full term parturient with HELLP syndrome and an intrauterine growth retarded (IUGR) baby, was scheduled for elective cesarean section. Twelve years back, she was diagnosed with TA, when she presented with dyspnea on exertion and a history of repeated blackouts. Since then she was regularly taking Tab prednisolone (Wysolone™, Wyeth Ltd.) aspirin and prazocin.

On examination, pulsations were found to be absent in her both carotids and left upper limb. She had a feeble pulse in right upper limb but peripheral pulses in both lower limbs were normal. Patient’s baseline blood pressure was 90/60 mmHg in right upper limb and 190/110 mmHg in right lower limb. The patient’s respiratory and neurological examination showed normal results. Preoperative investigations showed three fold elevated liver enzymes and low platelet count of 65,000, which increased to 1,50,000 after transfusion of single donor aphaeretic platelets. Rest of the investigations and fundus examination were within normal limits. Doppler examination confirmed the presence of bilateral carotid and right subclavian artery stenosis with normal renal arteries. Echocardiography showed the presence of normal left ventricular function with an ejection fraction of 50-55%, trivial mitral regurgitation and no regional wall motion abnormality.

In the operating room, baseline monitoring and invasive BP through the right dorsalis pedis artery was done. 20G epidural catheter was placed in L3-L4 interspace, followed by subarachnoid block with 6.5 mg  hyperbaric bupivacaine (0.5%) and 25 µg fentanyl in the same interspace. There after the patient was placed in supine position, with a left lateral tilt, and oxygen was administered via a face mask. Ephedrine boluses were used for hypotensive episodes. She remained hemodynamically stable in the intraoperative period and had an uneventful postoperative course.

Four types of TA have been described in the literature¹, with Type I involving the aortic arch and its main branches, Type II being restricted to the descending thoracic and abdominal aorta, Type III combining both Types I and II and patients with Type IV showing involvement of even the pulmonary artery. Our patient was categorized as Type I, with involvement of the carotids and the brachiocephalic trunk. Ishikawa² graded TA based on the presence of four major complications i.e., hypertension, retinopathy, aneurysm formation and aortic regurgitation.

Pregnancy does not change the evolution of TA but increases risk of decompensation of hypertension.³ Peripheral vascular resistance normally decreases during pregnancy. As patients with TA have stenotic vessels and a decrease in afterload, blood pressure increases secondary to the increase in the blood volume that accompanies pregnancy⁴. These patients are known to have end-organ dysfunction as a result of severe uncontrolled hypertension and major arterial stenosis. They may also be receiving chronic steroid treatment and may present with Cushingoid features preoperatively. In such cases, perioperative steroid supplementation is needed to prevent the occurrence of Addisonian hypotensive crises.^3,5,6 Invasive pressure monitoring is required in these patients to avoid hypoperfusion of brain and compromised fetus

In the past, both regional and general anesthesia has been used successfully in these patients^5,6 The choice of anesthetic technique should take into consideration maintenance of blood pressure in the intraoperative and postoperative periods. Regional anesthesia is preferred as level of consciousness and adequacy of cerebral perfusion can be better assessed in an awake patient. Moreover, according to previous reports, patients with preeclampsia are also benefited with regional anesthesia⁷ However, use of regional anesthesia in patients with TA might cause a precipitous fall in blood pressure due to sympathetic blockade, that may be hazardous in patient with compromised regional circulation because of stenosed arteries.³ So, in our patient, we decided to use low dose spinal anesthesia and supplement it with epidural block. A decrease in blood pressure was prevented with adequate preloading, Tredelenburg position and vasopressors. However, one needs to be very cautious while using vasopressors in patients with preexisting compromised organ perfusion.

General anesthesia, on the other hand, is associated with major hemodyanamic fluctuations during induction, intubation and extubation which can increase blood pressure to dangerous levels in patients with severe preeclampsia. Drastic hypotension may be precipitated with drugs such as propofol, thiopentone, and inhalational anesthetic agents.

To conclude, in patients with TA complicated by severe preeclampsia and compromised fetus, goal is to maintain or improve intrauterine perfusion while keeping patient’s vital signs stable. We conclude that combined spinal-epidural anesthesia is safer in these patients as no additional neurological monitoring is required and hemodynamics are better controlled.

REFERENCES

1. Lupi-Herrera E, Sanchez-Torres G, Marcushamer J, Mispireta J, Horwitz S, Vela JE.et al. Takayasu’s arteritis: clinical study of 107 cases. Am Heart J 1977;93:94–102. [PubMed]
2. Ishikawa K. Natural history and classification of occlusive thromboaortopathy (Takayasu’s disease). Circulation 1978;57:27–35. [PubMed] [Free Full Text]
3. Check TG, Gutsche BB. Maternal physiologic changes during pregnancy. In: Anesthesia for obstetrics. Shnider SM, Levinson G, eds. Baltimore: Williams & Wilkins, 1987:3–13.
4. Kathirvel S, Chavan S, Arya VK, Rehman I, Babu V, Malhotra N, et al. Anesthetic management of patients with Takayasu’s arteritis: a case series and review. Anesth Analg 2001;93:605. [PubMed] [Free Full Text]
5. Sharma BK, Jain S, Vasishta K. Outcome of pregnancy in Takayasu arteritis. Int J Cardiol 2000;75:159-62. [PubMed]
6. Van Bogaert LJ. Spinal block for caesarean section in parturient with PIH. East Afr Med J 1998;75:227–31. [PubMed]
7. Ishikawa K, Matsuura S. Occlusive thromboaortopathy (Takayasu’s disease) and pregnancy. Clinical course and management of 33 pregnancies and deliveries.  Am J Cardiol 1982;50:1293–300. [PubMed]