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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 6  |  Page : 858 Table of Contents     

Takayasu's Arteritis:Anaesthetic Implications and Role of ILMA for Airway Management


1 Specialist, Department of Anesthesiology, Maulana Azad Medical College and LN hospital, New Delhi 110002, India
2 Assosciate Professor, Department of Anesthesiology, Maulana Azad Medical College and LN hospital, New Delhi 110002, India
3 Ex.Director Professor and Head, Department of Anesthesiology, Maulana Azad Medical College and LN hospital, New Delhi 110002, India

Date of Acceptance25-Sep-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Prachi Gaba
KC- 22B, Phase- I, Ashok Vihar, New Delhi 110052
India
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Source of Support: None, Conflict of Interest: None


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Takayasu arteritis is a chronic progressive inflammatory vasculitis affecting aorta and its branches. We discuss a 24 year old posted for post partum sterilization. Patient had weak carotid pulsation on right and absent pulsations on left side. We used Intubating Laryngeal Mask Airway(ILMA) #4 to intubate the patient preventing any extension of the neck.

Keywords: Takayasu′s arteritis, ILMA


How to cite this article:
Gaba P, Saxena KN, Dua C K. Takayasu's Arteritis:Anaesthetic Implications and Role of ILMA for Airway Management. Indian J Anaesth 2008;52:858

How to cite this URL:
Gaba P, Saxena KN, Dua C K. Takayasu's Arteritis:Anaesthetic Implications and Role of ILMA for Airway Management. Indian J Anaesth [serial online] 2008 [cited 2020 Sep 22];52:858. Available from: http://www.ijaweb.org/text.asp?2008/52/6/858/60702


   Introduction Top


Takayasu's arteritis is a chronic progressive in­flammatory vasculitis of unknown etiology that has spe­cific predilection for young women [1] . It mainly affects aorta and its branches leading to narrowing, occlusion or dilatation of varying degrees. Hence it is also known as aortic arch syndrome, pulseless disease or occlu­sive thromboaortopathy. Although mostly found in Asians [2] , it occurs sporadically throughtout the world. It involves the vascular system leading to involvement of various organs, thus has special implications for the anaesthetists. This report discusses the anaesthetic man­agement of a patient suffering from this condition sched­uled for postpartum sterilization.


   Case report Top


A 24-year-old para 2 with two live issues who had a normal vaginal delivery 36 hours back was sched­uled for postpartum sterilization. The patient was a di­agnosed case of Takayasu's disease since five years. Bilateral renal stenting and right carotid stenting with coronary angioplasty had already been done, and since then the patient was on aspirin 75 mg once daily.

Preoperative physical examination revealed 55kg female. Weak carotid pulsations were palpable on the right side, while the left carotid pulsations were not palpable at all. Upper limb pulses were impalpable while normal pulsations were present in both lower limbs. Korotkoff sounds were inaudible in upper limb arteries but the automated non-invasive arterial blood pressure monitor was able to measure blood pressure in right upper limb which was 100/54 mm Hg while the blood pressure in lower limb on both side was 110/70 mm Hg. Though the patient had no neurological deficit, how­ever extension of neck resulted in vertigo and light­headedness signifying a compromised cerebral circu­lation. Hematological and biochemical investigations were found to be within limits. Chest x-ray and ECG revealed no pathological findings.

Thereafter, the patient was taken up for surgery .She received tab diazepam 10 mg night before sur­gery. On the day of surgery, five lead ECG was ap­plied to the patient along with pulse oximeter that was able to pick signals in upper limbs. Blood pressure cuff was applied to the right upper limb and on the right thigh. Fentanyl 50 µg was given. Anaesthesia was in­duced with propofol 125 mg and muscle relaxation was achieved with rocuronium 30 mg. Intubating Laryngeal Mask Airway (ILMA) size four was introduced with­out extension of the atlanto-occipital joint and intuba­tion achieved through it using size 7.5 flexo-metallic endotracheal tube in the first attempt. Nitrous oxide 33% and halothane 0.6% in oxygen was used for main­tenance of anaesthesia. Intraoperative period was un­eventful. Surgery lasted for 35 min and duration of ana­esthesia was 45 min. At the end of surgery the effect of muscle relaxant was reversed with neostigmine prior to extubation. The recovery period and post-operative course was unremarkable.


   Discussion Top


Takayasu's arteritis is a form of granulomatous vasculitis of aorta and its major branches. Takayasu in 1908 [2] brought to attention a clinical syndrome charac­terized principally by ocular disturbances and marked weakening of pulses of upper extremity. Takayasu's disease appears to have predilection for persons of Asian ethnic origin although it has a worldwide occur­rence [3] . In Japan an autopsy survey suggested a fre­quency of 1 in 3000 persons [4] . In an American study incidence of Takayasu's disease was found to be 2.6 new cases/million/year [5] . No figures are available of its incidence in the Indian population.

The disease is of unknown origin and has been found to be linked to tuberculosis, syphilis, streptococcal infection, rheumatic fever, collagen vascular disease, genetic factors and hypersensivity [6] , but none of these proposed causes have proven etiological link. Current opinion favors autoimmune mechanism as the cause, but there is no compelling evidence to support this either. It has a strong female predominance with fe­male: male ratio of 9:1 [1] . It has been classified on the basis of distribution of affected vessels [7] .

Classification of Takayasu's disease is shown in [Table 1] [8] .

Anaesthesiologist encounters these patients dur­ing obstetrical anaesthesia, incidental surgery or cor­rective vascular procedures. Clinically the patient pre­sents with absence of various pulses in the upper half of the body. A summary of major pathological features is shown in [Table 2] [9] .

Preoperative assessment of a patient with Takayasu's disease must take into account the distri­bution of arteritis and degree of organ involvement. The influence of changing head position on cerebral func­tion should be evaluated because hyperextension of head during laryngoscopy may further compromise blood flow through shortened and obstructed carotidartery [10],[11] . Previous reports of anaesthetic management have emphasized the importance and difficulties of ad­equate cardiovascular monitoring [11] . In our case inva­sive monitoring was deemed unnecessary taking into account the minor nature of scheduled surgical procedure and the fact that arterial blood pressure could be monitored using automated noninvasive blood pressure monitor and pulse oximeter in right arm. It is important while doing invasive monitoring of blood pressure that tip of the catheter be placed proximal to the area of arteritis as there is a difference in blood pressure proxi­mal and distal to the area of arteritis. Hung et al [12] assessed central system blood pressures in a patient with Takayasu's syndrome and found that aortic systolic and diastolic pressures were 100 to 120 mm Hg over and above those obtained in the upper limbs peripherally. However a moderate degree of correlation was ob­served between the central blood pressures and those obtained peripherally in the lower extremities by oscillometer or doppler method. Therefore we used non­invasive automated blood pressure monitoring based on the oscillometery principle. History of vertigo with neck extension signified compromised cerebral perfu­sion. Laryngoscopy was deemed impossible as laryngoscopy requires proper positioning of head which leads to extension at C1-2& C2-3 vertebrae [13] , thus further decreasing carotid blood flow. On the other hand intubation through ILMA has been radiographically re­viewed and evaluated with respect to the degree of angulation between occiput, C 1, C 2, and C 5 before the beginning of intubation and at the point of possible maximum movement of the skull and cervical spine while using ILMA . No significant variation in degree of flex­ion or extention of the cervical spine [14] during intubation using the ILMA was found. Therfore blind insertion of ILMA was done with neck in the neutral position and intubation achieved easily through the ILMA in the first attempt.

Other points of consideration include prevention of hypotension, which may further reduce abnormal regional blood flows. Maintenance of cerebral perfu­sion during anaesthesia is important in Takayasu's dis­ease. Intraoperative EEG monitoring has been used to detect cerebral ischaemia. One patient has reported cerebral infarction after general anaesthesia in recon­ structive surgery [14] .

In conclusion our case was young female with type III Takayasu arteritis who was successfully adminis­tered general anaesthesia without any untoward out­comes. Having used the ILMA successfully in our pa­tient with compromised cerebral circulation, we sug­gest that ILMA could be used as an alternative to laryn­goscopy for intubation in similar patients . However further evaluations are required in this regards.

 
   References Top

1.Bleck TP. Takayasu's disease. In Toole JF, ed. Hand­book of clinical neurology. Vol 11. Chicago: Elsevier, 1989;335-340.  Back to cited text no. 1      
2.Takayasu M. A case with peculiar changes of the cen­tral retinal vessels. Acta Societatis Ophthalmologiceae Japonicae 1908; 12: 554-555.  Back to cited text no. 2      
3.Kerr GS, Hallahan CW, Giordono J, et al. Takayasu's Arteritis. Ann Intern Med 1994; 120:919-29.  Back to cited text no. 3      
4.Nasu T. Takayasu's truncoarteritis in Japan. A statisti­cal observation of 76 autopsy cases. Pathol Microbiol (Basel) 1975;43:140-6.  Back to cited text no. 4  [PUBMED]    
5.Hewill S, Barr W, Lie JT, et. al. Takayasu Arteritis Study of 32 North American patients. Medicine (Baltimore) 1985; 64: 89.  Back to cited text no. 5      
6.Hawth JC, Cunnigham FG, Young B K. Takayasu's syn­drome In pregnancy. Obstetrics and Gynaecology 1977; 50: 373-75.  Back to cited text no. 6      
7.Ishikawa K, Matsuvra S. Occlusive thromboaortopathy (Takayasu's Arteritis) and pregnancy. Am J Cardiol 1982; 50: 1293-300.  Back to cited text no. 7      
8.Ishikewa I. Natural history and classification of occlu­sive thromboaortopathy. Circulation 1978; 57: 27-35.  Back to cited text no. 8      
9.Ramanathan S, Gupta U, et al. Anaesthetic consider­ation in Takayasu's arteritis Anesth Analg 1979; 58: 247-49.  Back to cited text no. 9      
10.Rivett DA, Sharples KJ, Milburn PD. Effect of premanipulative tests on vertebral artery and internal carotid artery blood flow: A Pilot Study. J Manipulative Physiol Ther 1999 ; 22:368-375.  Back to cited text no. 10      
11.A Meikle and B Milne. Extreme arterial blood pressure differentials in a patient with Takayasu's arteritis. Cana­dian Journal of Anesthesia 1997;44: 868-871.  Back to cited text no. 11      
12.Hung N, et al. Severe Takayasu's arteritis in pregnancy­the role of central haemodynamic monitoring. Am J Obstet Gynenco 1988;159:1135-6.  Back to cited text no. 12      
13.Waltl H, Melischek M,et al.Tracheal intubation and cer­vical spine excursion: direct laryngoscopy vs intubat­ing laryngeal mask . Anaesthesia 2001;56:221-226.  Back to cited text no. 13      
14.Faweet WJ, Razis P A, Berwick EP. Post operative cere­bral infarction and takayasu disease. European J of Anesthesiology 1993; 10: 33-35.  Back to cited text no. 14      



 
 
    Tables

  [Table 1], [Table 2]



 

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