Aortic surgeries are done all over the world by the vascular surgery community in large numbers.Its a major surgery and therefore adequate planning goes into it before the surgery is undertaken except in emergent situations like ruptured AAA etc.Inspite of the best efforts of the surgeon/surgical team end result may not be favorable in some cases.
I have till date presented a goody goody picture about the vascular surgery cases we do as routine but everyday is not Sunday.We present to you such a case wherein the patient developed complications due to supraceliac clamping.
Supraceliac clamping becomes mandatory in certain Vascular emergencies and therefore is an important tool in the toolkit of a Vascular surgeon but is not without complications.Significant heamodynamic changes take place due to SCC and therefore the Anaesthesia team should closely team up with their Vascular Surgeons.
Acute ischemic hepatitis is a known complication of SCC but not reported widely. Acute ischemic hepatitis is caused by poor hepatic perfusion and most often is associated with circulatory failure. AIH may also be caused by regional impedance of blood flow to the liver, specifically after celiac axis occlusion or supraceliac aortic clamping.Although the definitive diagnosis of AIH is established by histopathology, it is acceptable to make a diagnosis of AIH based solely on clinical and biochemical criteria, like
(1) Hypotension or low cardiac output
(2) Increase in serum transaminases, specifically an acute rise in AST to more than 1,000 IU/L
(3 ) Brief elevation of serum transaminases that lasts from 5 to 10 days.
(4) The serum bilirubin increases but rarely more than four times normal.
Mortality in patients with AIH is quite high with some reports claiming it to the tune of 60%(HICKMAN&POTTER).
Our patient had supraceliac clamping that lasted almost for 30 minutes.Intra and Post operatively patient developed hypotension and was supported by vasopressors( This may have added insult to injury).Patient went into hepatic encephalopathy and inspite of our best efforts could not be saved.
THE MESSAGE IS VERY CLEAR.THOUGH UNCOMMON,AIH SHOULD ALWAYS BE AT THE BACK OF OUR MINDS WHEN GOING IN FOR SCC AND THE CONCERNS SHOULD BE PASSED ON TO THE ATTENDANTS/PATIENTS DIRECTLY BEFORE UNDERTAKING A PROCEDURE LIKE THIS.
