Rapid Ventricular Transvenous Pacing via Pulmonary Artery Catheter: Deliberate Hypotension Technique for Precise Proximal Thoracic Aortic Stent Graft Deployment

Abstract

Deliberate hypotension facilitates precise deployment of endovascular stent grafting in the thoracic aorta. We describe a practical technique using pulmonary artery catheter (PAC) guided transvenous rapid ventricular pacing via transjugular approach and delineate pertinent anesthetic considerations. Anesthesiologists performed PAC guided rapid ventricular pacing in thirty-nine (39) patients (27 men and 12 women, mean age 74 ± 11 years) undergoing thoracic endograft deployment for aneurysm repair. Patient characteristics, hemodynamic parameters, pacing rate, and number of pacing events were recorded. Post-operative complications were evaluated. PAC guided rapid ventricular pacing successfully provided controlled hypotension without technical complications. Mean pacing rate was 177 ± 17 beats/min with an average of 2.6 ± 2 pacing events/surgical procedure. Average pacing duration was 34 ± 29 seconds (MAP of 47 ± 5 mmHg). One intraoperative death occurred in a patient with severe valvular heart disease. In all other cases, recovery time to baseline hemodynamics was short. Postoperative complications included atrial fibrillation in five patients (12%), elevated troponin levels in eight (21%), and stroke in three (8%). No patients had PAC related complications. Pulmonary artery catheter guided rapid ventricular pacing allows for accurate deployment of thoracic aorta endovascular stent-grafts. Patients with severe valvular or ischemic heart disease are likely poor candidates for this technique.