Anaesthetic management of a patient with pancreatic pseudocyst with thrombosis of multiple large vessels and intraventricular septum of the heart for open cystogastrostomy

Pancreatic pseudocyst associated with multiple large vessels in a patient suffering from pancreatitis is rarely described in literature. Earlier case reports have mentioned involvement of inferior vena caval (IVC) thrombosis. However additional involvement of bilateral common iliac vein, left main pulmonary artery and intraventricular septum was seen in our case. The anaesthetic purview of this rare case being an increased risk of intra operative embolism, the choice of anaesthetic technique was focused on minimizing hemodynamic fluctuations and providing adequate post-operative analgesia. Therefore thoracic epidural analgesia with general anaesthesia, combined with invasive monitoring was deemed as a safe option with successful outcome in this case. Pathophysiology of thrombus formation in pancreatic patients, preoperative optimisation, role of intraoperative invasive monitoring and postoperative management has been discussed.