Introduction: Endovascular aortic interventions are suitable alternatives to open surgery, being less invasive and having lower mortality and complications. Accurate positioning of the stent graft is a critical point because of systolic thrush. Techniques used to prevent it include pharmacological (antihypertensive drugs, nitroglycerin, adenosine) and mechanical methods (temporary caval occlusion by balloon). Rapid Right Ventricular Pacing (RRVP) is an emerging alternative with good patient tolerance and low level of complications.
Methods: A 79 years-old male, American Society of Anaesthesiology (ASA) status 3 (hypertension, chronic obstructive pulmonary disease and hyperuricemia), with an aortic arch aneurysm previously submitted to an ascendant aortic debranching, was proposed for Thoracic Endovascular Aortic Repair (TEVAR). ASA standard, invasive blood pressure, depth of anaesthesia and cerebral oximetry monitoring were used.
Results: Patient was sedo-analgesiated with Midazolam 2mg and Fentanyl 100mcg. A flow directed Pacing catheter was passed through an 8.5FR introducer inserted in right internal jugular vein. RRVP was tested to a cardiac frequency of 180 without patient complaint. Two vascular Valiant Thoracic endoprosthesis were placed through a femoral access. At the time of testing position and prothesis deployment, RRVP was started and systolic blood pressure dropped to 50mmHg. After stopping the RRVP in both placements, normal rhythm and blood pressure were observed. No relevant changes in cerebral monitoring were found. Final angiography showed no endoleak of prosthesis. The patient was admitted at Post- -Anaesthetic Care Unit and discharged after 24hours.
Conclusion: RRVP results in accelerated heart rate, with consequent decrease of intra-aortic blood flow, allowing more precise graft deployment without displacement, which is associated with lower incidence of endoleak. The faster onset of RRVP and rapid return to normal values can shorten the duration of the procedure. The procedure is done with minimal sedation, important in individuals with poor clinical status. This also allows to continually monitor the patient's neurologic status, possibly detecting any prosthetic displacement or acute event. Most complications are puncture- related. Rhythm-associated complications can occur in patients with heart diseases. In this case, no cardiac events were found. RRVP has been used in TEVAR with reliable results and is a good option for difficult cases. It's associated with a lower incidence of complications and less secondary effects than traditional measures, allowing to maintain patients with mild sedation, shortening hospital's length of stay. RRVP seems to be advantageous over traditional methods of controlling blood pressure in patients submitted to TEVAR.