A 46-year-old, 86 kg male with past medical history of non-insulin dependent type II diabetes mellitus, hyperlipidemia, hypothyroidism, gout, history of Hodgkin's lymphoma status after chemoradiation therapy (in remission), and recent diagnosis of bilateral carotid artery stenosis and pheochromocytoma presented for laparoscopic adrenalectomy. Six months prior, the patient experienced acute slurred speech, numbness, and left facial twitching while on a fishing trip. Non-contrast head CT scan was obtained and normal. With spontaneous resolution of symptoms, he was diagnosed with a transient ischemic attack (TIA) and discharged home with close follow-up with his primary care provider.
One week later, a non-contrast brain MRI demonstrated a right frontal cortex infarct. CT angiogram of the neck and chest demonstrated 60% stenosis of the left common carotid artery and 60-70% stenosis of the right common carotid artery. Subsequent bilateral carotid artery duplex study showed proximal right common carotid artery with severe stenosis (70-99% occlusion), proximal right internal carotid artery with mild stenosis (1-49% occlusion), proximal left common carotid artery with moderate stenosis (50-69% occlusion), and proximal left internal carotid artery with mild stenosis (1-49% occlusion). His vascular surgeon considered him a poor candidate for minimally invasive intervention of the right and potentially left common carotid arteries due to prior neck radiation, and he was scheduled to undergo carotid endarterectomy.
The patient was also being evaluated for a growing right adrenal mass noted on abdominal CT scan obtained to monitor for recurrence of Hodgkin's lymphoma. CT scan 3 years prior demonstrated a 1.2 cm right adrenal mass, but as he was asymptomatic, a watch, wait, and re-evaluate approach was taken. His most recent CT scan demonstrated that the right adrenal mass had increased in size to 2.2 cm. Around this time, the patient endorsed difficulty in managing his previously well-controlled diabetes, orthostasis, neuropathy in bilateral hands and feet, and occasional muscle cramps. He denied any known family history of endocrine tumors or personal history of hypertension, flushing, palpitations, rapid heartbeat, or headache. Subsequent lab testing was notable for a 24-hour urine normetanephrine of 1400 pg/mL and free normetanephrine of 3.9 pg/mL, and the patient developed significantly elevated blood pressures. He was referred to general surgery for consultation regarding right adrenalectomy for suspected pheochromocytoma. During this time, the patient developed worsening symptoms including consistently elevated blood pressure and heart rate and increasing challenges controlling his blood glucose levels.
The patient's endocrinologist prescribed PO doxazosin for alpha blockade with instructions for home blood pressure and heart rate monitoring. The patient was instructed to increase his dose of doxazosin every 3-4 days until his seated systolic blood pressure was consistently between 90-120 mmHg and his heart rate between 60-70 bpm. He was additionally instructed to maintain a daily sodium intake of greater than 5000 mg and maintain adequate fluid hydration. Once alpha blockade was achieved, he was started on beta blockade with PO atenolol.
On the morning of surgery, the patient presented with well-controlled blood pressure with BP 123/75 mmHg. His anesthesiologist and general surgeon contacted the patient's vascular surgeon to discuss the risks and benefits of proceeding with pheochromocytoma resection prior to carotid intervention. The multidisciplinary team agreed it was appropriate to proceed with adrenalectomy and plan for carotid intervention after postoperative recovery.
The patient was subsequently taken to the operating room for retroperitoneoscopic right adrenalectomy. He was premedicated with 4 mg IV midazolam, and a preinduction arterial line was placed. Induction of general anesthesia was achieved with lidocaine and propofol with rocuronium for muscle paralysis, and intubation was performed successfully on the first attempt with direct laryngoscopy. Bilateral cerebral oximetry was used to monitor cerebral oxygen saturation throughout the case. Sevoflurane was used for maintenance of anesthesia. Ketamine boluses were administered for anti-nociception. Dexamethasone and ondansetron were administered for postoperative nausea and vomiting (PONV) prophylaxis. A total of 10 units of insulin were administered to treat blood glucose elevations in the low 300 s. Intraoperative hypotension following resection of the tumor was treated with volume resuscitation with crystalloid and norepinephrine and vasopressin infusions and boluses. Cerebral oximetry remained within 20% of baseline throughout. The operation was performed without complication.
Following the operation, the patient was extubated and brought to PACU in stable condition. Postoperative pain was well controlled with oxycodone and acetaminophen. Postoperative course was relatively uneventful with the exception of persistent hyperglycemia requiring consultation of the inpatient endocrinology service, while in the hospital, the patient's blood pressure medications were held and his blood pressure remained well controlled. On postoperative day 1, the patient was alert and oriented, vitals were stable, and pain was well controlled, ambulating with very little assistance, tolerating a regular diet, and voiding independently. He was sent home with instructions to follow-up with endocrinology and general surgery and to continue to closely monitor his blood pressure.