Resection of Pheochromocytoma in a Patient Requiring Coronary Artery Bypass Grafting: First Things First

ABSTRACT Objective: Surgical management of critical ischemic heart disease in a patient with a pheochromocytoma poses a significant challenge for endocrinologists, surgeons, and anesthesiologists in terms of the sequence and optimal interval between operations for each condition. This case report exemplifies the practical problem of how to manage two major surgical procedures with their interrelated effects on outcome. Methods: We report on a patient with pheochromocytoma who presented with symptoms of severe multivessel coronary artery disease during medical preparation for pheochromocytoma surgery, requiring coronary artery bypass grafting (CABG). Results: A 74-year-old woman was diagnosed with a symptomatic pheochromocytoma of the right adrenal gland. After 3 days of presurgical preparation with the alpha-adrenoceptor blocker phenoxybenzamine, she presented with symptoms of multivessel ischemic heart disease, for which CABG was required. A successful two-stage procedure was carried out, first performing CABG under protection of phenoxybenzamine, followed by successful laparoscopic adrenalectomy a few weeks later. Both procedures had an uneventful course without major blood pressure fluctuations. Conclusion: Although it is important that the surgical approach is individualized in patients with the concurrent presence of a pheochromocytoma and critical ischemic heart disease, cardiac revascularization under alpha-adrenoceptor blockade prior to pheochromocytoma removal is generally the preferred sequence as this carries the lowest risk of complications. Abbreviations: CABG = coronary artery bypass grafting CAD = coronary artery disease