|Year : 2008 | Volume
| Issue : 6 | Page : 858
Takayasu's Arteritis:Anaesthetic Implications and Role of ILMA for Airway Management
Prachi Gaba1, Kirti N Saxena2, CK Dua3
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 Acceptance||25-Sep-2008|
|Date of Web Publication||19-Mar-2010|
KC- 22B, Phase- I, Ashok Vihar, New Delhi 110052
Source of Support: None, Conflict of Interest: None
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|| |
Takayasu's arteritis is a chronic progressive inflammatory vasculitis of unknown etiology that has specific predilection for young women  . 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  , 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|| |
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|| |
Takayasu's arteritis is a form of granulomatous vasculitis of aorta and its major branches. Takayasu in 1908  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  . In Japan an autopsy survey suggested a frequency of 1 in 3000 persons  . In an American study incidence of Takayasu's disease was found to be 2.6 new cases/million/year  . 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  , 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  . It has been classified on the basis of distribution of affected vessels  .
Classification of Takayasu's disease is shown in [Table 1]  .
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]  .
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 , . Previous reports of anaesthetic management have emphasized the importance and difficulties of adequate cardiovascular monitoring  . 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  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  , 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  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  .
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|| |
|1.||Bleck TP. Takayasu's disease. In Toole JF, ed. Handbook of clinical neurology. Vol 11. Chicago: Elsevier, 1989;335-340. |
|2.||Takayasu M. A case with peculiar changes of the central retinal vessels. Acta Societatis Ophthalmologiceae Japonicae 1908; 12: 554-555. |
|3.||Kerr GS, Hallahan CW, Giordono J, et al. Takayasu's Arteritis. Ann Intern Med 1994; 120:919-29. |
|4.||Nasu T. Takayasu's truncoarteritis in Japan. A statistical observation of 76 autopsy cases. Pathol Microbiol (Basel) 1975;43:140-6. [PUBMED] |
|5.||Hewill S, Barr W, Lie JT, et. al. Takayasu Arteritis Study of 32 North American patients. Medicine (Baltimore) 1985; 64: 89. |
|6.||Hawth JC, Cunnigham FG, Young B K. Takayasu's syndrome In pregnancy. Obstetrics and Gynaecology 1977; 50: 373-75. |
|7.||Ishikawa K, Matsuvra S. Occlusive thromboaortopathy (Takayasu's Arteritis) and pregnancy. Am J Cardiol 1982; 50: 1293-300. |
|8.||Ishikewa I. Natural history and classification of occlusive thromboaortopathy. Circulation 1978; 57: 27-35. |
|9.||Ramanathan S, Gupta U, et al. Anaesthetic consideration in Takayasu's arteritis Anesth Analg 1979; 58: 247-49. |
|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. |
|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. |
|12.||Hung N, et al. Severe Takayasu's arteritis in pregnancythe role of central haemodynamic monitoring. Am J Obstet Gynenco 1988;159:1135-6. |
|13.||Waltl H, Melischek M,et al.Tracheal intubation and cervical spine excursion: direct laryngoscopy vs intubating laryngeal mask . Anaesthesia 2001;56:221-226. |
|14.||Faweet WJ, Razis P A, Berwick EP. Post operative cerebral infarction and takayasu disease. European J of Anesthesiology 1993; 10: 33-35. |
[Table 1], [Table 2]