Severe intraoperative hypertensive crisis during surgery for phaeochromocytoma/paraganglioma: analysis of pre-operative risk factors.

Background: Phaeochromocytoma and paraganglioma (PPGL) pose an operative challenge, as their manipulation may induce abrupt catecholamine release and severe intraoperative hypertensive crisis (SIHC), which may lead to severe outcomes. While alpha-blockade is standard it may not eliminate this risk and some evidence has challenged its routine use. We seek to understand which pre-operative factors are linked to SIHC. Methods: Retrospective study of a single-centre, single surgeon cohort of patients who underwent PPGL resection. Primary outcome was SIHC, secondary outcomes included overall and major complications, length of stay and vasopressor need at 24 hours from surgery. Results: Forty patients were included in the analysis. Eighty percent of patients were female with a median age of 58 years. The most common presenting symptom was hypertension (60%), while 15% presented with a clinically significant event [syncope, stroke or myocardial infarction (MI)]. SIHC occurred in 10% of patients and was significantly associated to presentation with a clinically significant event (P<0.001), especially MI (P=0.008), and to left-sided tumours (P=0.02). After 24 hours 60% of patients were on vasopressors, most commonly females (P<0.04) and those with high preoperative normetanephrine levels (P=0.02). There were no major complications while overall complications were linked to open surgery (P=0.02). Conclusions: Patients presenting with a clinically significant event and those with left-sided tumours may be more likely to develop SIHC. This knowledge may inform clinical practice, especially anaesthesiological preoperative planning, and guide patient inclusion in upcoming studies.