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Year : 2022  |  Volume : 1  |  Issue : 2  |  Page : 80-82

Aortoiliac occlusive disease with situs inversus totalis: Anesthetic management of a rare association

1 Department of Anaesthesiology, Rajiv Gandhi Superspeciality Hospital, Delhi, India
2 Department of CTVS, Rajiv Gandhi Superspeciality Hospital, Delhi, India

Date of Submission21-Jul-2022
Date of Acceptance15-Aug-2022
Date of Web Publication02-Dec-2022

Correspondence Address:
Dr. Charu Sharma
Department of Anaesthesiology, Rajiv Gandhi Superspeciality Hospital, Delhi - 110 093
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jica.jica_21_22

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Situs inversus totalis (SIT) is a rare, autosomal recessive congenital anomaly, in which the major visceral organs are reversed from their normal position. Their unique anatomy and association with various congenital anomalies may present various challenges during anesthetic management. We report a case of SIT with aortoiliac occlusive diseases who underwent axillobifemoral bypass grafting surgery. We aim to discuss the anesthetic considerations and implications associated with such patients.

Keywords: Aortoiliac occlusive disease, axillobifemoral grafting, situs inversus totalis

How to cite this article:
Sharma C, Jain R, Jain A, Roy A. Aortoiliac occlusive disease with situs inversus totalis: Anesthetic management of a rare association. J Ind Coll Anesth 2022;1:80-2

How to cite this URL:
Sharma C, Jain R, Jain A, Roy A. Aortoiliac occlusive disease with situs inversus totalis: Anesthetic management of a rare association. J Ind Coll Anesth [serial online] 2022 [cited 2023 Oct 1];1:80-2. Available from: https://www.jicajournal.in//text.asp?2022/1/2/80/362610

  Introduction Top

Situs inversus is a rare congenital morphological anomaly of positioning of internal viscera characterized by transposition of abdominal and thoracic viscera. When it is associated with dextrocardia, it is called situs inversus totalis (SIT).[1] The incidence varies from 1:5000 to 1:20,000 births.[2],[3] The recognition of SIT is important to facilitate optimal anesthetic management, especially when invasive hemodynamic monitoring is required.

Axillofemoral bypass grafting is a surgical procedure for patients with aortoiliac occlusive disease to improve arterial blood flow to the lower extremities. The presence of aortoiliac occlusive disease in SIT is uncommon. We report a case of SIT with aortoiliac occlusive disease posted for right axillobifemoral bypass grafting.

  Case Report Top

A 44-year-old male presented with complaints of intermittent claudication in the bilateral lower limbs for the past 10 months. He was taking medications for hypertension (tablet telmisartan 40 mg once a day) and was a smoker for the last 20 years. On cardiovascular examination, the apex beat was located at the right 5th intercostal space 1.5 cm medial to mid-clavicular line, and heart sounds were heard on the right side of the chest. Bilateral upper limbs pulses were palpable while bilateral femoral pulses were feeble. Electrocardiography of the patient displayed marked right-axis deviation with inverted P wave in lead I and aVL and positive wave in avR [Figure 1]. Echocardiography showed inferior vena cava on the left side, aorta on the right side, normal left ventricular function, and ejection fraction of 55%. Chest radiography revealed dextrocardia with fundal gas shadow on the right side [Figure 2]. Ultrasonography of the abdomen revealed liver and gall bladder on the left side and spleen and stomach on the right side, with reversal of aorta and inferior vena cava position. Computed tomography angioaortogram revealed aortoiliac occlusive disease with bilateral collateral formation, complete occlusion of juxta renal abdominal aorta, and bilateral external and internal iliac artery. There were multiple collaterals draining the bilateral distal external iliac artery [Figure 3].
Figure 1: Electrocardiogram showing marked right-axis deviation with negative P wave in lead I and aVL

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Figure 2: Chest X-ray showing dextrocardia and right-sided gastric air bubble indicating the situs inversus totalis

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Figure 3: Complete occlusion of juxta renal abdominal aorta and bilateral external and internal iliac arteries. Bilateral collateral arteries including superior and inferior mesenteric and lumbar arteries

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He was planned for right axillobifemoral bypass. In the operation theater, good intravenous access was secured. After reverse placement of electrocardiography leads, left radial artery cannulation and left-sided internal jugular vein cannulation were done. Anesthesia was induced with injection fentanyl 100 μg, injection propofol 100 mg, and injection vecuronium 5 mg intravenously. Maintenance was done with isoflurane and intermittent vecuronium boluses. The duration of the procedure was 160 min (uneventful).

Reversal of neuromuscular blockade was done with injection glycopyrrolate 0.4 mg and injection neostigmine 2.5 mg intravenously. Extubation was smooth. The patient was transferred to postanesthesia care unit. Postoperative analgesia was maintained with intermittent injection diclofenac 75 mg and injection paracetamol 1 g infusion. The patient was discharged after an uneventful postoperative course on day 5.

  Discussion Top

SIT can coexist with other congenital anomalies, such as cardiovascular (ventricular septal defect, atrial septal defect, tetralogy of Fallot, and transposition of great arteries), respiratory (bronchiectasis, paranasal sinus deformity, and sinusitis), digestive system (anal atresia, duodenal stenosis, absent appendix, and megacolon), spinal deformities (split cord, spina bifida, meningomyelocele, and scoliosis), and liver and renal abnormalities.[4]

When SIT is associated with sinusitis and bronchiectasis, it is called Kartagener's syndrome.[5] Hence, precise diagnosis of situs inversus and a thorough systemic evaluation are necessary to minimize various potential intraoperative adverse events.

In patients with aortoiliac occlusive disease not amenable to endovascular intervention, aortobifemoral bypass or axillofemoral bypass is the surgical procedure.[6],[7] Our patient underwent right axillobifemoral bypass grafting under general anesthesia, and the intraoperative period was uneventful.

On reviewing the literature, we found a case report which used along with subarachnoid block for axillofemoral bypass.[8] In another literature, local anesthesia was given in two patients not fit for general anesthesia, with one patient requiring sedation.[9] However, none of the patients had associated SIT.

Anesthetic management of such patients should focus on the following:

  • Reverse placement of electrocardiograph electrodes (to prevent any myocardial ischemic findings) and, if required, defibrillator pads (for adequate delivery of shock)
  • In Kartagener's syndrome, optimization of pulmonary status should be done with postural drainage, physiotherapy, antibiotics, bronchodilators, and incentive spirometry by avoiding nasal intubation (in associated sinusitis)
  • There are more chances of left endobronchial intubation since the left bronchus is more in line with the trachea due to transposition of thoracic viscera, and successful intubation and lung separation may not be accomplished without the aid of fiberoptic bronchoscope[5]
  • Ultrasound-guided procedures should be done if there is a need for invasive central venous cannulation (preferably left-sided) and brachial plexus blockade
  • For neuraxial blockade, associated spina bifida, scoliosis, and meningomyelocele should be looked for
  • A case of prolonged paralysis after administration of succinylcholine has been reported (possible link between situs inversus and atypical cholinesterase).[10]

  Conclusion Top

Patients with SIT are asymptomatic and have a normal life expectancy. Diagnosis of SIT is important when dealing with such patients to prevent inadvertent intraoperative complications. Our case report stresses the need of thorough preoperative evaluation to detect associated anomalies and intraoperative vigilance, for successful outcome of such patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Applegate KE, Goske MJ, Pierce G, Murphy D. Situs revisited: Imaging of the heterotaxy syndrome. Radiographics 1999;19:837-52.  Back to cited text no. 1
Takei HT, Maxwell JG, Clancy TV, Tinsley EA. Laparoscopic cholecystectomy in situs inversus totalis. J Laparoendoscopic Surg 1992;2:171-6.  Back to cited text no. 2
Varano NR, Merklin RJ. Situs inversus: Review of the literature, report of four cases and analysis of the clinical implications. J Int Coll Surg 1960;33:131-48.  Back to cited text no. 3
Koç A. Situs inversus totalis. Anästh Intensivmed 2021;62:S211-20.  Back to cited text no. 4
Reidy J, Sischy S, Barrow V. Anaesthesia for Kartagener's syndrome. Br J Anaesth 2000;85:919-21.  Back to cited text no. 5
Schneider JR, McDaniel MD, Walsh DB, Zwolak RM, Cronenwett JL. Axillofemoral bypass: Outcome and hemodynamic results in high-risk patients. J Vasc Surg 1992;15:952-62.  Back to cited text no. 6
Passman MA, Taylor LM, Moneta GL, Edwards JM, Yeager RA, McConnell DB, et al. Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease. J Vasc Surg 1996;23:263-9.  Back to cited text no. 7
Cappello E, Di Lorenzo M, Cutillo E, Franco E. Axillofemoral bypass in elderly patients with local anesthesia: An alternative route to less risk. BMC Surg 2013;13:1-2.  Back to cited text no. 8
Al-Wahbi A. Axillofemoral bypass with local anesthesia: A way forward to enable limb salvage in high-risk patients. Local Reg Anesth 2010;3:129-32.  Back to cited text no. 9
Thakuria R, Singh A. Situs inversus totalis and anesthesia; challenging aspects. JCAO 2019;3:2.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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