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Anesthesia for endovascular aortic repair

Author
E. Andrew Ochroch, MD, MSCE
Section Editor
Peter D Slinger, MD, FRCPC
Deputy Editor
Nancy A Nussmeier, MD, FAHA

INTRODUCTION

Endovascular aortic repair (EVAR) has become a standard approach to treatment for thoracic and abdominal aortic aneurysms, accounting for well over half the patients who would otherwise undergo an open surgical repair. Since EVAR does not require intrathoracic or intraabdominal exposure of the aorta, or aortic cross-clamping, perioperative morbidity and mortality are reduced compared with open repair. Also, EVAR has made treatment possible for some patients with comorbidities who might not otherwise be candidates for aortic repair.

Vascular access for EVAR is achieved through access to the femoral vessels, either percutaneously or via small incisions; thus, the procedure may be accomplished with the aid of local anesthesia with monitored anesthesia care, neuraxial regional anesthesia, or general anesthesia. This topic will review the preoperative anesthesia consultation and each of these anesthetic options for thoracic or abdominal EVAR. The surgical techniques and endovascular devices used for EVAR, as well as complications of the procedure, are discussed in detail elsewhere. (See "Endovascular repair of the thoracic aorta" and "Endovascular devices for thoracic aortic repair" and "Endovascular repair of abdominal aortic aneurysm" and "Endovascular devices for abdominal aortic repair" and "Complications of endovascular abdominal aortic repair".)

PREANESTHETIC ASSESSMENT

Most patients with thoracic and/or abdominal aortic aneurysm are older and have major cardiac and other comorbidities (eg, coronary artery disease, hypertension, obesity, diabetes, hyperlipidemia, smoking, and chronic obstructive pulmonary disease). Although endovascular aortic repair (EVAR) is associated with lower perioperative morbidity and mortality compared with open surgical repair, there is some risk that conversion to open (eg, intrathoracic or intraabdominal) repair will become necessary [1,2]. Thus, the preoperative evaluation is as thorough for EVAR as that for open repair. (See "Endovascular repair of the thoracic aorta", section on 'Medical risk assessment' and "Endovascular repair of the thoracic aorta", section on 'Preoperative preparation' and "Endovascular repair of abdominal aortic aneurysm", section on 'Preoperative risk assessment'.)

Cardiovascular assessment — Either thoracic or abdominal EVAR is considered to be a procedure associated with intermediate risk for a perioperative cardiovascular event (at least 1 percent) [1,2]. We agree with the recommendations made in the 2014 American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Anesthesiology guidelines regarding evaluation and management of cardiac risk in patients undergoing intermediate-risk noncardiac surgery [1,3,4].

We obtain a preoperative electrocardiogram (ECG) since it is useful to have a baseline ECG if the postoperative ECG is abnormal. The preoperative ECG is evaluated for Q-waves or significant ST-segment elevation or depression (which raises the possibility of myocardial ischemia or infarction), left ventricular hypertrophy, QTc prolongation, bundle-branch block, or arrhythmia.

                                   

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Literature review current through: Nov 2016. | This topic last updated: Wed Oct 21 00:00:00 GMT+00:00 2015.
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References
Top
  1. Kristensen SD, Knuuti J. New ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J 2014; 35:2344.
  2. Schermerhorn ML, O'Malley AJ, Jhaveri A, et al. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008; 358:464.
  3. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215.
  4. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77.
  5. Cuypers PW, Buth J. Does endovascular aortic aneurysm repair justify a reduced cardiology work-up? J Cardiovasc Surg (Torino) 2003; 44:437.
  6. Karthikesalingam A, Thrumurthy SG, Young EL, et al. Locoregional anesthesia for endovascular aneurysm repair. J Vasc Surg 2012; 56:510.
  7. De Virgilio C, Romero L, Donayre C, et al. Endovascular abdominal aortic aneurysm repair with general versus local anesthesia: a comparison of cardiopulmonary morbidity and mortality rates. J Vasc Surg 2002; 36:988.
  8. Lee WA, Daniels MJ, Beaver TM, et al. Late outcomes of a single-center experience of 400 consecutive thoracic endovascular aortic repairs. Circulation 2011; 123:2938.
  9. Jankovic Z, Ahmad N, Ravishankar N, Archer F. Transversus abdominis plane block: how safe is it? Anesth Analg 2008; 107:1758.
  10. Edwards MS, Andrews JS, Edwards AF, et al. Results of endovascular aortic aneurysm repair with general, regional, and local/monitored anesthesia care in the American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg 2011; 54:1273.
  11. Lippmann M, Lingam K, Rubin S, et al. Anesthesia for endovascular repair of abdominal and thoracic aortic aneurysms: a review article. J Cardiovasc Surg (Torino) 2003; 44:443.
  12. Aadahl P, Lundbom J, Hatlinghus S, Myhre HO. Regional anesthesia for endovascular treatment of abdominal aortic aneurysms. J Endovasc Surg 1997; 4:56.
  13. Martin DE, Rosenberg H, Aukburg SJ, et al. Low-dose fentanyl blunts circulatory responses to tracheal intubation. Anesth Analg 1982; 61:680.
  14. Qi DY, Wang K, Zhang H, et al. Efficacy of intravenous lidocaine versus placebo on attenuating cardiovascular response to laryngoscopy and tracheal intubation: a systematic review of randomized controlled trials. Minerva Anestesiol 2013; 79:1423.
  15. Griffin RM, Kaplan JA. Myocardial ischaemia during non-cardiac surgery. A comparison of different lead systems using computerised ST segment analysis. Anaesthesia 1987; 42:155.
  16. Stern S. State of the art in stress testing and ischaemia monitoring. Card Electrophysiol Rev 2002; 6:204.
  17. Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2009; 120:e169.
  18. Ellis JE, Shah MN, Briller JE, et al. A comparison of methods for the detection of myocardial ischemia during noncardiac surgery: automated ST-segment analysis systems, electrocardiography, and transesophageal echocardiography. Anesth Analg 1992; 75:764.
  19. Landesberg G, Mosseri M, Wolf Y, et al. Perioperative myocardial ischemia and infarction: identification by continuous 12-lead electrocardiogram with online ST-segment monitoring. Anesthesiology 2002; 96:264.
  20. Swaminathan M, Lineberger CK, McCann RL, Mathew JP. The importance of intraoperative transesophageal echocardiography in endovascular repair of thoracic aortic aneurysms. Anesth Analg 2003; 97:1566.
  21. Fattori R, Caldarera I, Rapezzi C, et al. Primary endoleakage in endovascular treatment of the thoracic aorta: importance of intraoperative transesophageal echocardiography. J Thorac Cardiovasc Surg 2000; 120:490.
  22. Rocchi G, Lofiego C, Biagini E, et al. Transesophageal echocardiography-guided algorithm for stent-graft implantation in aortic dissection. J Vasc Surg 2004; 40:880.
  23. Rapezzi C, Rocchi G, Fattori R, et al. Usefulness of transesophageal echocardiographic monitoring to improve the outcome of stent-graft treatment of thoracic aortic aneurysms. Am J Cardiol 2001; 87:315.
  24. Gonzalez-Fajardo JA, Gutierrez V, San Roman JA, et al. Utility of intraoperative transesophageal echocardiography during endovascular stent-graft repair of acute thoracic aortic dissection. Ann Vasc Surg 2002; 16:297.
  25. Swaminathan M, Mackensen GB, Podgoreanu MV, et al. Spontaneous echocardiographic contrast indicating successful endoleak management. Anesth Analg 2007; 104:1037.
  26. American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010; 112:1084.
  27. Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2015; 28:40.
  28. Reeves ST, Finley AC, Skubas NJ, et al. Special article: basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2013; 117:543.
  29. Gaibazzi N, Rigo F, Lorenzoni V, et al. Comparative prediction of cardiac events by wall motion, wall motion plus coronary flow reserve, or myocardial perfusion analysis: a multicenter study of contrast stress echocardiography. JACC Cardiovasc Imaging 2013; 6:1.
  30. Koolen JJ, Visser CA, Reichert SL, et al. Improved monitoring of myocardial ischaemia during major vascular surgery using transoesophageal echocardiography. Eur Heart J 1992; 13:1028.
  31. London MJ, Tubau JF, Wong MG, et al. The "natural history" of segmental wall motion abnormalities in patients undergoing noncardiac surgery. S.P.I. Research Group. Anesthesiology 1990; 73:644.
  32. Eisenberg MJ, London MJ, Leung JM, et al. Monitoring for myocardial ischemia during noncardiac surgery. A technology assessment of transesophageal echocardiography and 12-lead electrocardiography. The Study of Perioperative Ischemia Research Group. JAMA 1992; 268:210.
  33. Feezor RJ, Martin TD, Hess PJ Jr, et al. Extent of aortic coverage and incidence of spinal cord ischemia after thoracic endovascular aneurysm repair. Ann Thorac Surg 2008; 86:1809.
  34. Freyrie A, Testi G, Gargiulo M, et al. Spinal cord ischemia after endovascular treatment of infrarenal aortic aneurysm. Case report and literature review. J Cardiovasc Surg (Torino) 2011; 52:731.
  35. Gravereaux EC, Faries PL, Burks JA, et al. Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms. J Vasc Surg 2001; 34:997.
  36. Ullery BW, Wang GJ, Woo EY, et al. No increased risk of spinal cord ischemia in delayed AAA repair following thoracic aortic surgery. Vasc Endovascular Surg 2013; 47:85.
  37. Baril DT, Carroccio A, Ellozy SH, et al. Endovascular thoracic aortic repair and previous or concomitant abdominal aortic repair: is the increased risk of spinal cord ischemia real? Ann Vasc Surg 2006; 20:188.
  38. Sloan TB, Jameson LC. Electrophysiologic monitoring during surgery to repair the thoraco-abdominal aorta. J Clin Neurophysiol 2007; 24:316.
  39. Nuwer MR, Emerson RG, Galloway G, et al. Evidence-based guideline update: intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Clinical Neurophysiology Society. Neurology 2012; 78:585.
  40. Nuwer MR, Emerson RG, Galloway G, et al. Evidence-based guideline update: intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials*. J Clin Neurophysiol 2012; 29:101.
  41. Sinha AC, Cheung AT. Spinal cord protection and thoracic aortic surgery. Curr Opin Anaesthesiol 2010; 23:95.
  42. Scheufler KM, Zentner J. Total intravenous anesthesia for intraoperative monitoring of the motor pathways: an integral view combining clinical and experimental data. J Neurosurg 2002; 96:571.
  43. Sloan TB, Koht A. Depression of cortical somatosensory evoked potentials by nitrous oxide. Br J Anaesth 1985; 57:849.
  44. Bala E, Sessler DI, Nair DR, et al. Motor and somatosensory evoked potentials are well maintained in patients given dexmedetomidine during spine surgery. Anesthesiology 2008; 109:417.
  45. Kawaguchi M, Sakamoto T, Inoue S, et al. Low dose propofol as a supplement to ketamine-based anesthesia during intraoperative monitoring of motor-evoked potentials. Spine (Phila Pa 1976) 2000; 25:974.
  46. Keyhani K, Miller CC 3rd, Estrera AL, et al. Analysis of motor and somatosensory evoked potentials during thoracic and thoracoabdominal aortic aneurysm repair. J Vasc Surg 2009; 49:36.
  47. Brown OW, Hollier LH, Pairolero PC, et al. Abdominal aortic aneurysm and coronary artery disease. Arch Surg 1981; 116:1484.
  48. Hammond EC, Garfinkel L. Coronary heart disease, stroke, and aortic aneurysm. Arch Environ Health 1969; 19:167.
  49. Walker SR, Yusuf SW, Wenham PW, Hopkinson BR. Renal complications following endovascular repair of abdominal aortic aneurysms. J Endovasc Surg 1998; 5:318.
  50. Youngblood SC, Tolpin DA, LeMaire SA, et al. Complications of cerebrospinal fluid drainage after thoracic aortic surgery: a review of 504 patients over 5 years. J Thorac Cardiovasc Surg 2013; 146:166.
  51. Ullery BW, Wang GJ, Low D, Cheung AT. Neurological complications of thoracic endovascular aortic repair. Semin Cardiothorac Vasc Anesth 2011; 15:123.
  52. Buth J, Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. a study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg 2007; 46:1103.
  53. Hanna JM, Andersen ND, Aziz H, et al. Results with selective preoperative lumbar drain placement for thoracic endovascular aortic repair. Ann Thorac Surg 2013; 95:1968.
  54. Fedorow CA, Moon MC, Mutch WA, Grocott HP. Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: rationale and practical considerations for management. Anesth Analg 2010; 111:46.
  55. Ullery BW, Cheung AT, McGarvey ML, et al. Reversal of delayed-onset paraparesis after revision thoracic endovascular aortic repair for ruptured thoracic aortic aneurysm. Ann Vasc Surg 2011; 25:840.e19.
  56. Tsusaki B, Grigore A, Cooley DA, Collard CD. Reversal of delayed paraplegia with cerebrospinal fluid drainage after thoracoabdominal aneurysm repair. Anesth Analg 2002; 94:1674.
  57. Mialhe C, Amicabile C, Becquemin JP. Endovascular treatment of infrarenal abdominal aneurysms by the Stentor system: preliminary results of 79 cases. Stentor Retrospective Study Group. J Vasc Surg 1997; 26:199.
  58. Shimazaki T, Ishimaru S, Kawaguchi S, et al. Blood coagulation and fibrinolytic response after endovascular stent grafting of thoracic aorta. J Vasc Surg 2003; 37:1213.