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A case of intraoperative coronary artery spasm in a patient with vascular disease
Masaki Ito1, Masachika Hayashi, Shin Kagaya
1Department of Anesthesiology, Nagano Matsushiro General Hospital, 183 Matsushiro, Matsushiro town, Nagano, Nagano 381-1231, Japan. masaki1104@hotmail.com
Insights
Perioperative coronary artery spasm (CAS) can occur in patients undergoing surgery for peripheral artery disease, even without prior heart issues. Prompt recognition and treatment of CAS symptoms like ECG changes are crucial for patient outcomes.
Area of Science:
- Cardiology
- Anesthesiology
- Vascular Surgery
Background:
- A 66-year-old male with significant cardiovascular risk factors (smoking, hypertension, hyperlipidemia, impaired glucose tolerance) underwent major vascular surgery.
- The patient had arteriosclerosis obliterans with iliac and popliteal arterial thrombus, necessitating a right aortofemoral bypass and thromboembolectomy.
Observation:
- During surgery under epidural and general anesthesia, the patient developed ST elevation and ventricular tachycardia shortly after skin incision.
- A sudden decrease in blood pressure accompanied the electrocardiogram (ECG) changes, prompting suspicion of coronary artery spasm (CAS).
Findings:
- Transesophageal echocardiography (TEE) revealed transient hypokinesis in specific myocardial segments, which resolved with observation.
- The patient's hemodynamics and ECG abnormalities were stabilized with rapid administration of vasodilators and vasopressors, supporting the diagnosis of CAS.
Implications:
- Perioperative CAS should be considered in patients with systemic arteriosclerosis, even in the absence of established coronary artery disease.
- Close ECG monitoring and prompt recognition of ischemic changes are vital during vascular surgery.
- Immediate diagnosis and therapeutic intervention for CAS can prevent adverse cardiac events and improve surgical outcomes.
Abstract:
A 66-year-old man with a history of longtime smoking, untreated hypertension, hyperlipidemia, and impaired glucose tolerance but no history of myocardial infarction or angina pectoris was scheduled for right aortofemoral bypass and thromboembolectomy for arteriosclerosis obliterans with right common iliac and right popliteal arterial thrombus. Epidural anesthesia and general anesthesia were administered without obvious ECG changes. Just after skin incision, ST elevation in leads II and V5 and a short run of ventricular tachycardia with frequent premature ventricular contractions (PVCs) were recorded on the ECG monitor, and the patient's blood pressure suddenly decreased within a few seconds. On noticing these changes, we suspected coronary artery spasm (CAS) and rapidly administered vasodilators and vasopressors to stabilize hemodynamics and ECG changes. Transesophageal echocardiography (TEE) showed basal to mid- and anteroseptal to inferior wall motion hypokinesis that gradually returned to normal during observation. Even in patients without coronary disease but with systemic arteriosclerosis, it is important to consider the possibility of perioperative CAS and not to overlook ECG changes. Immediate diagnosis and treatment are essential.
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