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Canadian Journal of Anesthesia 50:970-971 (2003)
© Canadian Anesthesiologists' Society, 2003

Correspondence

Severe bradycardia in a patient undergoing endovascular stent-graft repair for abdominal aortic aneurysm with vena cava balloon occlusion

Yuko Sato, MD, Tomomasa Kimura, MD PhD, Eiichi Sato, MD, Kimitoshi Nishiwaki, MD PhD and Yasuhiro Shimada, MD PhD FCCP

Nagoya, Japan

To the Editor:

Endovascular stent-graft deployment (SGD) for repair of an aortic aneurysm has recently been preferred to aneurysmectomy in certain cases.1 We encountered severe dysrhythmias in a patient undergoing SGD.

A 73-yr-old male with infrarenal abdominal aortic aneurysm underwent endovascular SGD due to reduced pulmonary function arising from a previous right thoracoplasty. The preoperative electrocardiogram revealed complete right bundle-branch block. Anesthesia was induced with propofol, fentanyl and vecuronium and maintained with sevoflurane and supplemental fentanyl.

A double-balloon catheter was inserted through the femoral vein and its position confirmed under fluoroscopic guidance. Subsequently, a sheath charged with the self-expandable stent was introduced via the left femoral artery.

Hypotension was induced by inflation of the occlusion balloon in the inferior vena cava (IVC) followed by gradual inflation of the balloon in the superior vena cava (SVC). Supraventricular arrhythmia ensued, followed by severe bradycardia (FigureGo). The mean arterial blood pressure decreased to 30 mmHg. Cardiac massage was performed accompanied by the iv administration of atropine (0.5 mg) and methoxamine (3 mg). After balloon deflation, the severe bradycardia recovered to normal sinus rhythm and arterial blood pressure was restored. Nine minutes after the bradycardia, only the balloon in the IVC was re-inflated, and arterial pressure decreased to 36 mmHg. No dysrhythmia occurred and the stent-graft was successfully deployed. The postoperative course was uneventful.



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  		FIGURE Hemodynamic tracings during balloon inflation for deployment of the stent-graft. Arrows A, B and C indicate the inferior vena cava balloon inflation, the superior vena cava balloon inflation and balloon deflation, respectively. ECG = electrocardiograph, ABP = arterial blood pressure, PAP = pulmonary arterial pressure, CVP = central venous pressure.

 
We used an occlusion catheter inserted via the femoral vein in both the SVC and IVC.2 The advantage of this method is the rapid induction of hypotension on balloon inflation and prompt recovery of blood pressure on deflation. The disadvantages include the excessive lowering of the blood pressure, originally targeted at 60 mmHg, to as low as 30 mmHg. Moreover, cerebral congestion due to impaired cerebral perfusion and/or arrhythmias, as encountered in this patient, are risks that cannot be ignored.

The sinoatrial node lies at the junction of the SVC and right atrium, just above the site of balloon occlusion.3 Severe bradycardia in the present case may have been triggered by the direct mechanical stimulus of the balloon pressing against the sinoatrial node. A sudden decrease of blood flow to the sinoatrial node could not be an alternative explanation for the severe bradycardia because IVC occlusion alone showed the same blood pressure decrease as the bicaval occlusion method without dysrhythmia.

In conclusion, we recommend that close attention be paid to critical arrhythmias on balloon inflation during the anesthetic management of endovascular SGD with vena cava balloon occlusion.

References

1 Blum U, Voshage G, Lammer J, et al. Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms. N Engl J Med 1997; 336: 13–20.[Abstract/Free Full Text]

2 Nishikimi N, Usui A, Ishiguchi T, Matsushita M, Sakurai T, Nimura Y. Vena cava occlusion with balloon to control blood pressure during deployment of transluminally placed endovascular graft. Am J Surg 1998; 176: 233–4.[Medline]

3 Anderson RH, Ho SY, Smith A, Becker AE. The internodal atrial myocardium. Anat Rec 1981; 201: 75–82.[Medline]





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