AORTIC STENOSIS IN A COMPLEX CASE OF MAJOR VASCULAR SURGERY

Introduction Aortic stenosis (AS) in non-cardiac surgery increases perioperative risk of complications (1) Methods Case report of single patient Results A 70-year-old lady with complicated type 2 diabetes with renal, retinal and coronary affection is admitted to a district general hospital (DGH) with a decompensated heart failure. She is known to have hypertension, restrictive pneumopathy due to obesity (Body Mass Index of 49), stable angor with 2 stents in circumflex and right coronary artery, a moderate AS with moderately impaired Left ventricular function, and an untreated umbilical hernia. On admission microcitic anaemia was diagnosed with hemoglobin of 7.4 g/dl thought to be due to NSAID administration. After red blood cell (RBC) transfussion and deplective treatment was instituted, her dyspnea improved. Nevertheless, after 10 days of hospital admission she started with fever and positive blood cultures for Enterococcus faecium and Staphylococcus aureus Methicillin-resistant (MRSA). No vegetation was found in transthoracic and transoesophageal echocardiography, CT brain was normal but in the CT of the abdomen a infrarenal pseudoaneurysm of the Aorta was evidenced. She was transferred to our centre for treatment of the mycotic pseudoaneurysm. Uppon arrival to a PET-scan confirmed the active infective focus in the infra-renal Aorta. She was started on daptomicin+ ceftaroline. Due to high risk of opened surgery an endovascular exclusion of pseudoaneurysm was proposed to prevent aortic rupture. Discussion with heart team took place and aortic ballon valvuloplasty was deemed too risky due to infection scenario and moderate grade of AS. Preoperative optimisation was performed increasing furosemide due to congestive lung signs in chest X-ray. Uppon her arrival at interventional radiology suite, she was monitored invasively with left radial artery blood pressure and central venous pressure via right internal yugular vein. Intraoperative approach was based on conscious sedation with remifentanil and local anaesthesia. Neverthless, equipment for converting to a general anaesthesia was prepared and a second consultant anaesthetist kept available to give assistance to this remote area in case of emergency. During the procedure she maintained tendency to hypertension with mean arterial pressure of 100-110 mmHg and central venous pressure of 22 mmHg. Total diuresis was 100 ml. Blood gas analysis revealed Hb of 8.5 g/dl, p02 of 120 mmHg with 35% of facemask oxygen and pCO2 of 38 mmHg. 1 unit of RBC was transfused. The pseudoaneurysm was excluded with no residual leak. Postoperatively, she was admitted to a surgical intensive care unit where she stayed for 20 hours. After 12 days of uncomplicated hospital admission, she was discharged to original DGH hospital. Discussion Aortic stenosis in vascular surgery modify perioperative approach including intraoperative monitoring, type of anaesthesia and postoperative ICU admission. Preoperative optimisation and multidisciplinar assessment via Heart team of Aortic valvuloplasty is recommended. We report a high risk patient with heart failure and moderate AS that underwent an uneventful endovascular exclusion of mycotic pseudoaneurysm under conscious sedation and local anaesthesia.