Strategies avoid aneurysm surgery complications in 83-year-old man
Performing procedure in summer among preventive measures, per case report
An 83-year-old man with cold agglutinin disease (CAD) underwent surgery for an abdominal aortic aneurysm — a bulging in the lower part of the aorta, the body’s largest blood vessel — without major complications thanks to several preventive strategies, a study reported.
To avoid complications from cold-induced hemolysis, or red blood cell destruction, the doctors kept the man’s body warm during surgery and used a minimally invasive surgical technique called endovascular aortic repair (EVAR) to repair the bulge while shortening the time under general anesthesia.
“Specific precautions are required for CAD if surgical intervention with general anesthesia is needed,” the researchers wrote.
The case report, “Abdominal Aortic Aneurysm with Primary Cold Agglutinin Disease Treated with Endovascular Aortic Repair,” was published in the Annals of Vascular Diseases.
CAD is a rare, autoimmune disease that occurs when self-reactive antibodies called cold agglutinins react with red blood cells at cold temperatures, causing them to clump and break down. This can lead to a deficient number of red blood cells to efficiently transport oxygen throughout the body, causing fatigue and other CAD symptoms, and result in the formation of blood clots that can cause additional complications.
Keeping warm during surgery
CAD can be classified as primary when its cause is unknown and secondary when it occurs due to an underlying condition, such as an infection, another autoimmune disease, or cancer.
Because CAD symptoms worsen at low temperatures, patients are at a higher risk of complications during major surgeries, when the operating room can be too cold and the body’s core temperature can get too low under general anesthesia.
While pretreatment with rituximab — a therapy that targets the immune cells that produce these antibodies — can be an effective preventive strategy in a surgical setting, the main strategy is still keeping patients warm.
The team of researchers in Japan reported the case of an 83-year-old man with CAD who underwent an EVAR surgery to treat an abdominal aortic aneurysm without major CAD-related complications.
The man had been living with a CAD diagnosis for nine years. His first symptoms were the Raynaud’s phenomenon, which occurs when the body’s extremities become numb and/or discolored in response to cold. Blood tests at that time came back positive for cold agglutinins and signs of hemolytic anemia, when red blood cells break down prematurely.
Based on these findings, he was diagnosed with CAD.
Subsequently, whenever the man was exposed to cold — in air conditioning, for example — he would get a lace-like, purple rash on his arms and legs, called livedo reticularis. He also showed jaundice, or yellowing of the skin and white parts of the eyes, because persistent hemolysis increases the levels of a yellowish molecule called bilirubin.
The man was referred to the researchers’ department due to an abdominal aortic aneurysm of 51 mm (about two inches), which is “a potentially life-threatening condition,” the researchers wrote.
To reduce the risk of complications from cold, the doctors scheduled the surgery for the aneurysm during the summer. The operating room was kept at 29 C (84.2 F), and his arms and legs were wrapped in pre-warmed blankets.
Also, all fluids administered to his bloodstream during surgery were warmed and maintained at 37 C (98.6 F). His core temperature was monitored using a sensor in his bladder and was kept steady between 37-38 C (between 98.6-100.4 F) throughout the surgical procedure.
The doctors also used more heparin, a blood thinner that helps prevent blood clots, than usual, giving him 80 units per kilogram instead of the typical 50.
After the surgical procedure, an imaging test showed that both iliac arteries — blood vessels that branch off from the aorta — were intact, and there was no sign of a leak. However, the man’s blood levels of hemoglobin, the protein in red blood cells that carries oxygen, dropped and his bilirubin levels increased, indicating CAD worsening.
He was transfused with red blood cells and haptoglobin, a protein that helps protect tissues from high levels of free hemoglobin, on the day of surgery, and after one and three days.
While “temporary hemolytic anemia and exacerbation of jaundice were observed postoperatively despite strict temperature control,” the researchers wrote, there were no serious complications, and the man was able to go home on the seventh day after surgery.
A follow-up CT scan confirmed that the abdominal aortic aneurysm was successfully treated.
At least two special precautions are required when performing surgery for abdominal aortic aneurysm in CAD patients, the team noted.
“First, surgery in winter should be avoided, as with all other surgeries,” the researchers wrote. “Second, EVAR should be the first choice for surgical technique selection if the anatomical conditions are favorable, as it allows for less intraoperative blood loss and shorter surgical and anesthesia times than open surgery does.”
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