Disclosures: Aye Mon Win, DO: Nothing to disclose

Case Description: The patient presented to a community hospital with chest pain radiating to the left shoulder and back, progressive hoarse voice, and shortness of breath. CT angiogram demonstrated an expanding 8-cm thoracic aortic aneurysm with penetrating ulcer and intramural hematoma. He was emergently transferred to an academic medical center where he underwent thoracic endovascular aortic repair with concomitant right carotid to left subclavian bypass, left common carotid ligation and distal anastomosis to bypass, and left subclavian coil embolization, complicated by endoleak requiring repair.

Setting: Tertiary care hospital, academic medical center, and acute rehabilitation hospital.

Patient: An 82-year-old male with past medical history of hypertension, hyperlipidemia, stroke, type 2 diabetes mellitus, and prior abdominal aortic aneurysm repair.

Assessment/Results: The patient’s rehabilitation course was complicated by supine hypertension with orthostatic hypotension (OH) with sitting blood pressures as low as 78/51 and standing blood pressures as low as 62/42. Anti-hypertensive medications were titrated down, abdominal binder and compression stockings were donned, fluid intake liberalized, and midodrine 5 mg BID with therapy was added.

Discussion: Despite reconditioning in acute inpatient rehabilitation and achieving euvolemia, the patient continued to struggle with OH with pre-syncope 6 months post-operatively. We hypothesize that this patient’s aortic aneurysm and surgically altered carotid anatomy have manipulated carotid baroreceptors, thereby impairing normal postural reflex mechanisms. This is the first reported case, to our knowledge, describing orthostatic hypotension after carotid-subclavian bypass with TEVAR.

Conclusion: Orthostatic hypotension is a ubiquitous challenge in acute inpatient rehabilitation. However, signs and symptoms often improve with reconditioning, physical countermeasures and pharmacologic management. As well as limiting therapy and hindering functional gains, when associated with cardiovascular disease, OH is associated with increased morbidity and all-cause mortality.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/refractory-orthostatic-hypotension-after-carotid-subclavian-bypass-with-tevar-a-case-report-of-a-common-problem-in-an-uncommon-patient/