Concomitant elective resection of pheochromocytoma and repair of aortic abdominal aneurysm
The patient is a 65-year-old male who came to the attention of the anesthesia service after being assessed by his primary care physician for hematuria. The patient’s medical history included: hypertension, hyperlipidemia, and myocardial infarction. In 1992, the patient underwent PTCA with stent placement. Work-up revealed elevated urinary metanephrines consistent with a diagnosis of pheochromocytoma, and CT scans showed a large right adrenal septated cystic mass that contained foci of fat and calcifications separate from the right kidney, as well as an infrarenal aneurysm. The aneurysm measured 5.4 cm × 4.9 cm. It extended down to include the left common iliac artery, measuring 2 cm in diameter.\nA decision was made to operate on the patient with a planned concomitant resection of the adrenal mass and repair of the abdominal aortic aneurysm (AAA) due to the patient bilateral occlusive iliac disease and involvement of the left common ileac artery by the aneurysm. Also three-dimensional reconstruction CT scan shows unsuitability for endovascular repair of aortic aneurysm (EVAR) due to aneurysm morphology.\nThe patient was continually managed by the endocrinology service for optimization of his hemodynamic status prior to surgical intervention. During the preoperative work-up, the patient demonstrated noncritical disease of left anterior descending and right coronary artery by cardiac catheterization. The Persantine myocardial study showed mild to moderate ischemia of the inferolateral wall with reduced left ventricular ejection fraction (45%).\nAs the patient was asymptomatic at this time, he was deemed fit to proceed to surgery with adequate beta blockade and optimization of his hemodynamic status. The patient was managed for approximately four months by the endocrinology team, who optimized his blood pressure with antihypertensive agents including phenoxybenzamine, isosorbide, and atenolol. The major goals in the anesthetic management of patients with pheochromocytoma and aortic aneurysm are maintenance of cardiovascular stability, and avoidance of tachycardia and hypertensive crisis. Our patient, perioperative, was hemodynamically optimized with alpha-1 and beta blockers preoperatively. We verified this clinically on the day of surgery by confirming orthostasis. Anticholinergic agents and sympathomimetic neuromuscular blocking agents were avoided. Depth of anesthesia was monitored with the use of a bispectral index monitor. Hemodynamic parameters remained stable throughout the induction of general anesthesia. A two-dimensional transesophageal echocardiography (TEE) was placed for monitoring of the cardiac function and evaluation of the extent and severity of the aortic pathology. Two-dimensional echocardiography is a sensitive and specific technique for detecting transient myocardial ischemia, and TEE monitoring is widely used to evaluate myocardial ischemia during cardiac surgery. However, data for the use of TEE during non-cardiac surgery are controversial if the patient is hemodynamically stable. Given the association of pheochromocytoma with AAA in a patient with ischemic heart disease, and its resultant poor prognoses, early diagnosis and early treatment of myocardial ischemia are critical. TEE provides important real-time information on cardiac filling and function, and is particularly useful when unexplained hemodynamic instability is encountered.\nThe initial phase of the procedure was the right adrenalectomy, which was achieved with minimal hemodynamic instability during manipulation of the tumor. The AAA repair proceeded after completion of adrenalectomy. Through the same incision the duodenum was mobilized off of the aneurysm over to the right side of the abdomen. The neck of the aneurysm was exposed and was continued distally to expose both iliac arteries. Heparin 6000 units were administered intravenously before attaining proximal and distal control. At aortic cross-clamping, the blood pressure swings were minimized by supplemental boluses of vasoactive drugs. The aorta was opened longitudinally with removal of large amounts of thrombus. A 16 mm graft was used in the repair. Prior to the time of release of the cross-clamp, the patient was loaded with 2 L of crystalloid fluid, and immediately after release of the cross-clamp, we noted hypotension, with empty cardiac chambers by TEE. Further fluids and pressers were administered, with good response. The patient continued to require low-dose norepinephrine, despite adequate volume resuscitation. This low-tone state was probably a combination of reduction in endogenous catecholamine levels post-adrenalectomy, residual alpha-blockade, and a systemic inflammatory state due to the stress of surgery. The remainder of the case proceeded uneventfully, and the patient was transferred to the ICU stable. Postoperative recovery was uneventful. Twelve months following surgery, the patient remained totally asymptomatic, normotensive, and on no antihypertensive medication.