Pulmonary Artery Catheter Directed Rapid Right Ventricular Pacing to Facilitate Precise Deployment of Endografts in the Thoracic Aorta: A Novel Approach

OBJECTIVES:: Controlled hypotension is critical for precise deployment of endografts in the thoracic aorta. Rapid right ventricular pacing (RRVP) via a transfemoral venous catheter has been reported previously as a technique to facilitate thoracic endograft placement. We describe a novel approach to RRVP using a pulmonary artery catheter (PAC) that is placed during the endograft procedure for hemodynamic monitoring.
METHODS: Clinical and radiological records of 16 patients (11 men, mean age 76 years) who underwent endograft placement in the thoracic aorta with PAC-directed RRVP were reviewed. Endografts were placed to treat thoracic aortic aneurysms (mean diameter 65 mm) in 10 patients, penetrating aortic ulcers in 3 patients, existing endoleaks in 2 patients and a left subclavian artery aneurysm. All endografts but three were deployed in the proximal aorta (zones 1-3). Hemodynamic parameters, accuracy of deployment, complications related to RRVP and PAC placement and presence of endoleaks were evaluated.
RESULTS: PAC-directed RRVP was performed during endograft deployment without technical difficulty in all patients. A median of two pacing episodes were performed for each patient. The mean duration of a pacing episode was 18 seconds. Mean pacing rate was 170 beats per minute, which achieved an average mean arterial pressure of 45 mm Hg . Following pacing cessation, recovery time of mean arterial pressure to pre-pacing levels was < 2 seconds. All endografts were deployed accurately with precise positioning at a mean of 2 mm from the intended placement site. No complications related to RRVP or PAC placement occurred. No type I endoleaks nor postoperative complications were observed. There was no perioperative mortality.
CONCLUSIONS:
PAC-directed RRVP is a safe and effective method of inducing hypotension, enabling precise thoracic endograft deployment. This technique is easily reproducible with short pacing intervals allowing rapid recovery of the baseline heart rate and mean arterial pressure. It avoids the use of femoral venous access and its associated potential complications, simplifying the procedure and utilizing resources readily available to the vascular surgeon.