STA-MCA bypass with severe uncontrolled HTN

Gabrielle Morris

46-year-old male with occluded left MCA

Background

  • Occluded MCA
    • Attempted stenting previously. Stent thrombosed intraoperatively, required thrombolysis
    • Progressive right sided weakness – recent onset
  • ? IHD
    • STEMI – angiogram showed only moderate diffuse disease
    • 2nd STEMI 2017 – angiogram showed spasm, resolved during PCI with intra-arterial vasodilator therapy
    • Regular cardiology review. Multiple therapies trialed for coronary artery spasm and hypertension
    • Patient cannot tolerate verapamil PO.
  • Grade 3 HTN
    • 200/110 in clinic. 
    • Since age 14yo. 
    • Symptomatic if SBP < 165. Dizzy and nauseated
    • Headache when SBP>240
    • Equal in both arms
    • Extensively investigated including renin-angiotension levels etc, no cause elucidated.
  • Non-smoker, no DM

Issues:

  • New ECG changes in clinic – TWI in I and V5-6 (? LVH although only mild LVH on recent TTE)
  • HTN unoptimised
  • Monthly chest pain – Responsive to GTN. 
  • Chest pain much improved since commencement of Diltiazem

Discussion

  • ​HTN
    • Symptomatic at values higher or lower than a specific range
    • Nil further perioperative management is indicated.
    • Neurosurgery team aware
    • BP targets post-op? Risk of hyperemic brain injury v. “hypotensive” infarct
  • Frequent CP
    • Given unremarkable angiogram findings, in keeping with coronary vasospasm
  • Level of postop care
  • ICU 2 vs 3
  • Postoperative BP will require close monitoring and control
  • Invasive BP measurement would be optimal
  • Ward setting unlikely to be suitable in first 24/48 hours

Plan:

  • Discuss with surgeons – “yes will need strict BP control and monitoring.”
  • ICU level 2 
  • Discuss new ECG changes with treating cardiologist
  • Notification of procedural anaesthetist
  • Continue all antihypertensives preop