Raj Sahajanandan

Externalized Guidewires to Facilitate Fenestrated Endograft Deployment in the Aortic Arch

Purpose: To describe a precannulated fenestrated endograft system utilizing externalized guidewires to facilitate aortic arch endovascular repair and to report its use in 2 patients with challenging anatomy. Technique: For distal arch repair, a fenestration for the left subclavian artery (LSA) is made onsite in a standard thoracic endograft tailored to the patient anatomy; it is precannulated with a nitinol guidewire (NGw), which is passed from the femoral artery and externalized from the left brachial artery prior to endograft delivery system introduction over a parallel stiff guidewire. Steps are then taken to remove guidewire intertwining, prevent NGw wrapping around the delivery system, and orient the LSA fenestration superiorly when the delivery system moves into the arch. Gentle traction on the ends of the NGw during endograft deployment facilitates proper fenestration alignment. A covered stent is deployed in the LSA fenestration. The technique is illustrated in a patient with congenital coarctation of the aorta and descending aortic aneurysm. For total arch repair, endograft fenestrations are made for all 3 arch branches; the left common carotid artery (LCCA) and LSA fenestrations are each cannulated with NGws, which travel together from the femoral artery, pass through a LSA snare loop, and are exteriorized from the LCCA. After endograft deployment, the innominate artery fenestration is separately cannulated using right brachial access. Placement of a parallel externalized hydrophilic guidewire passing through the LCCA fenestration (but not the LSA snare loop) and removal of the LCCA fenestration NGw allows exteriorization of the LSA fenestration NGw from the left brachial artery by pulling the LSA snare. Covered stents are deployed in all 3 fenestrations. The technique is presented in a patient with type B aortic dissection. Conclusion: Use of the precannulated fenestrated endograft system described is feasible and has the potential to make aortic arch endovascular repair simpler, more reliable, and safer.

Regional anesthesia in patients with pregnancy induced hypertension

Pregnancy induced hypertension is a hypertensive disorder, which occurs in 5% to 7% of all pregnancies. These parturients present to the labour and delivery unit ranging from gestational hypertension to HELLP syndrome. It is essential to understand the various clinical conditions that may mimic preeclampsia and the urgency of cesarean delivery, which may improve perinatal outcome. The administration of general anesthesia (GA) increases morbidity and mortality in both mother and baby. The provision of regional anesthesia when possible maintains uteroplacental blood flow, avoids the complications with GA, improves maternal and neonatal outcome. The use of ultrasound may increase the success rate. This review emphasizes on the regional anesthetic considerations when such parturients present to the labor and delivery unit.

Intraoperative transesophageal echocardiography assessment of right atrial myxoma resulting in a change of the surgical plan

Transesophageal echocardiography (TEE) is an important diagnostic tool. It provides structural and functional assessment of cardiac structures which can improve the overall outcome of the patient. We present a case with right atrial myxoma in which TEE helped to find the attachment of the mass so that overall surgical plan was changed.

A randomized controlled trial comparing the myocardial protective effects of isoflurane with propofol in patients undergoing elective coronary artery bypass surgery on cardiopulmonary bypass, assessed by changes in N-terminal brain natriuretic peptide

Objective: The objective of the study is to compare the myocardial protective effects of isoflurane with propofol in patients undergoing elective coronary artery bypass surgery on cardiopulmonary bypass (CPB), the cardio protection been assessed by changes in N-terminal brain natriuretic peptide (NT proBNP). Methodology and Design: This study is designed as a participant blinded, prospective randomized clinical trial. Setting: Christian Medical College Hospital, Vellore, India. Participants: Patients undergoing elective coronary artery bypass surgery on CPB. Intervention: Anesthesia was maintained with 0.8–1.2 end tidal concentrations of isoflurane in the isoflurane group and in the propofol group, anesthesia was maintained with propofol infusion as described by Roberts et al. Measurements: Hemodynamic data were recorded at frequent intervals during the surgery and up to 24 h in the Intensive Care Unit (ICU). The other variables that were measured include duration of mechanical ventilation, dose and duration of inotropes in ICU, (inotrope score), duration of ICU stay, NT proBNP levels before induction and 24 h postoperatively, creatine kinase-MB levels in the immediate postoperative, first and second day. Results: Mean heart rate was significantly higher in propofol group during sternotomy, (P = 0.021). Propofol group had a significantly more number of patients requiring nitroglycerine in the prebypass period (P = 0.01). The increase in NT proBNP from preoperative to postoperative value was lesser in the isoflurane group compared to propofol even though the difference was not statistically significant. The requirement of phenylephrine to maintain mean arterial pressure within 20% of baseline, mechanical ventilation duration, inotrope use, duration of ICU stay and hospital stay were found to be similar in both groups. Conclusion: Propofol exhibit comparable myocardial protective effect like that of isoflurane in patients undergoing coronary artery bypass graft surgery. Considering the unproven mortality benefit of isoflurane and the improved awareness of green OT concept, propofol may be the ideal alternative to volatile anesthetics, at least in patients with good left ventricular function.

Anesthetic challenges of a patient with the communicating bulla coming for nonthoracic surgery

Management of a patient with a giant bulla coming for a nonthoracic surgery is rare, and its anesthetic management is very challenging. It is imperative to isolate only the subsegmental bronchus, in which the bulla communicates to avoid respiratory morbidities such as pneumothorax, emphysema or atelectasis of the surrounding lung parenchyma, and postoperative respiratory failure. Herewith, we want to report the anesthetic challenges of a patient with giant bulla communicating into one of the subsegmental right upper lobe bronchus for splenectomy.

Lutembacher syndrome: Dilemma of doing a tricuspid annuloplasty

We discuss the case of a 24-year-old woman with Lutembacher syndrome and severe tricuspid regurgitation (TR) who underwent surgical closure of atrial septal defect and mitral valve replacement without tricuspid annuloplasty despite a severe TR and a large tricuspid annulus on preoperative echo. The pathophysiology of Lutembacher syndrome is discussed below. The utility of perioperative echocardiography in assessing the annular diameter, tenting area and coaptation depth and thus providing insights into the functioning of the tricuspid valve will also be emphasized.

Inverted left atrial appendage masquerading as a left atrial mass

An inverted left atrial appendage after cardiac surgery is a rare finding and can be misinterpreted as a thrombus, mass, or vegetation. We report a case where intraoperative transesophageal echocardiography assisted in making an accurate diagnosis.

Wire guided fibreoptic retrograde intubation in a case of glottic mass

Sir, A 65-year-old gentleman presented to our Otorhinolaryngology department, with a history of progressive change in voice and noisy breathing. Pre-operative nasopharyngolaryngoscopy revealed an exophytic growth involving left vocal cord extending into vestibule, arytenoid and anterior one-third of the right vocal cord. The left hemi larynx was fixed with restricted mobility of the right vocal cord as well, with posterior airway of 4–5 mm. A diagnosis of carcinoma glottis was made and he was posted for micro laryngoscopy and biopsy under general anaesthesia. Pre-anaesthetic evaluation of airway was Mallampati III with mild limitation of neck extension, thyromental distance of 5 cm and mouth opening of 3 finger breadths. The pre-operative room air saturation was 97% and inspiratory stridor was audible. The patient was not prescribed any sedative premedication, due to compromised airway. The life-saving back-up plan was emergency tracheostomy. Our plan A was to proceed with awake fibreoptic intubation technique. Intravenous access was secured and monitors were placed as per the American Society of Anesthesiologists guidelines. An informed consent was taken after explaining the risks and benefits of the procedure. The patients airway was topicalised with bilateral superior laryngeal nerve block and transtracheal block using 2% preservative-free lignocaine. Nebulisation was given using 4% lignocaine, and 10% lignocaine was used to spray the nostrils and supraglottic structures. Likewise, oxymetazoline was used to vasoconstrict the nasal mucosa. The total dose of local anaesthetic was kept within 9 mg/kg. The patient was very cooperative throughout the performance of airway blocks. A 4.0 mm fibreoptic bronchoscope (KARL STORZ) with a size 5.0 cuffed micro laryngoscopy endotracheal tube was loaded over it and introduced into the right nostril. The mass was seen occupying most of the supraglottic space, with no visible airway. It was oedematous, friable and we were reluctant to push the fibreoptic bronchoscope past it, blindly. It was observed that the mass had increased in size since last naso-pharyngo-laryngoscopy (NPL) [Figure 1]. We decided to proceed with wire-guided fibreoptic intubation, using a Terumo© urological J-tipped guide wire (size: 0.032 inches/150 cm). Figure 1 Nasopharyngolaryngoscopy depiction of exophytic proliferative growth involving most supraglottic structures, with airway seen as slit-like opening beyond the growth The cricothyroid membrane was identified and punctured in a cephalad direction, using an 18-gauge intravenous cannula (Insyte©). The cannula placement was confirmed by aspirating air, with a saline-filled syringe. Following this, the guide wire was introduced in a retrograde fashion through the cannula, with fibreoptic bronchoscope in position above the supraglottic mass. The guide wire was negotiated posterior to the mass and brought out through the right nostril. It was then passed through the working channel of fibreoptic bronchoscope. The bronchoscope was advanced over guide wire and gradually guided below the mass and into vocal cords [Figure 2]. Once fibreoptic bronchoscope tip reached the point of entry of guide wire in trachea, the guide wire was removed and the bronchoscope was navigated distally into the trachea. Our patient was fairly comfortable during the procedure, secondary to adequately anaesthetised airway and we were constantly talking to him, as we advanced step-by-step. Figure 2 Panel (a) depicts an oedematous mass occupying the supraglottic space, as seen with C-Mac© videolaryngoscope; followed by panel (b) with a view of the passing Terumo© urological J-tipped guide wire Retrograde intubation, a technique developed in the 1960s by Butler and Cirillo, had been frequently used for difficult intubation prior to the advent of flexible fibreoptic bronchoscopy.[1,2,3] In patients, where a patent airway is not visible, passing fibreoptic bronchoscope blindly can lead to undue complications such as trauma, laryngospasm, bleeding and further worsening of an already compromised airway. Hence, by combining both techniques, the advantages afforded by both can be superimposed to our benefit. In the method described above, the J-tipped guide wire used is PTFE (Polytetrafluoroethylene) coated, which is kink-resistant and non-irritant to mucosal surfaces. After piercing the cricothyroid membrane, the flexible J-tip is directed upwards towards the glottis, allowing this thin (0.032 inch) wire to be negotiated via the narrowest available path with least resistance. In case any obstruction is encountered, the tip can be torqued to facilitate navigation into the larynx, while simultaneously visualising its entry from above by the fibreoptic bronchoscope. Conventional[4] teaching dictates holding the catheter taut at both the entry and exit points during retrograde intubation. However, endotracheal tube or fibreoptic bronchoscope can abut[5] against the cricothyroid membrane hindering their smooth passage. Hence, we kept the guide wire lax, which proved very instrumental in advancing the fibreoptic bronchoscope into the trachea. The guide wire is easily available in urological theatres and due to its small size, it can be used with paediatric fibreoptic bronchoscope also. To conclude, the inclusion of retrograde intubation technique in difficult airway algorithm[6] underlines the importance of inculcating this time-tested skill, at trainee level. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

An innovative way to reinsert dislodged Arndt blocker using urological glide wire.

The Arndt blocker is positioned in the desired bronchus using a wire loop which couples the blocker with a fiberoptic bronchoscope (FOB). The wire loop once removed cannot be reinserted in 5F and 7F blockers making repositioning of the blocker difficult. A 34-year-old female was to undergo left thoracotomy followed by laparoscopic cholecystectomy. The left lung was isolated with a 7F Arndt bronchial blocker. During one-lung ventilation, the wire loop was removed for oxygen insufflation. There was loss of lung isolation during the procedure and dislodgement of the blocker was confirmed by FOB. The initial attempts to reintroduce the blocker into the left main bronchus failed. An alternative technique using a glide wire was attempted which resulted in successful reintroduction of the Arndt blocker. The 0.032 inch zebra glide wire may be effectively used to reposition a dislodged Arndt blocker if the wire loop has been removed.

Case report of aortopulmonary window with undiagnosed interrupted aortic arch: Role of transesophageal echocardiography

Fifty percent of these cases have associated cardiovascular anomalies, so it is important to look for these associated anomalies of heart and great vessels.[2] Preoperative imaging such as TTE, Doppler studies, and hemodynamic catheterization should be carried out to rule out these coexisting anomalies.[3‐5] In our case, preoperative evaluation of TTE and CTA failed to diagnose IAA,[3,4] probably due to the continuous flow of DTA through PDA and also a possibility of human error.[2]