AAA

Considerations :
1. Hemodynamic liability
 Pre-clamp hypertension with massive increase in LV afterload
 Post -clamp hypotension with compromised organ perfusion
 Unclamping
2. Perioperative myocardial ischemia/infarction risk high
3. Potential for massive blood loss
 Hemorrhage
 Coagulopathy
4. Co-morbid illnesses
 DM, HTN, CAD, smoking, PVD, COPD, RF
5. Potential emergency situation for an acute rupture

Goals :
Maintain hemodynamic neutrality as best as possible. Maintain normal
cardiac chamber size, maintain proximal perfusion and be prepared to manage
the changes induced with aortic X-clamp and de-clamping. Recognize the need
for postoperative pain control. Optimize myocardial supply/demand ratio and
recognize the high incidence of perioperative MI.

Background :
Prevalence of abdominal aortic aneurysms among elderly males ~8%
Age, smoking, + family history of abdominal aortic aneurysm, and
atherosclerotic disease are risk factors for abdominal aortic aneurysm.
Due to an aging population the incidence is steadily rising!
Approximately 5% of patients undergoing abdominal aortic resection
have inflammatory aneurysms
Rare causes of abdominal aortic aneurysm disease include trauma,
mycotic infection, syphilis, and Marfan’s syndrome.
For ruptured abdominal aortic aneurysms, the perioperative mortality
rate has not changed significantly over the past 4 decades and remains nearly
50%, and those are the patients that make it to the hospital....
Elective repair should be undertaken in all abdominal aortic aneurysms
with a diameter of 6 cm or greater (with no debate.)
Although some controversy exists regarding elective abdominal aortic
aneurysm repair when diameter is in the 5.5- to 5.9-cm range, it is currently
accepted that the risk of rupture for a 5.5-cm aneurysm (per year) is equal to
or greater than perioperative mortality, and surgical repair is indicated.
The risk of rupture may be higher in women.
For aneurysms less than 5.5 cm, surgical repair is often recommended if
such aneurysms become symptomatic or expand more than 0.5 cm in a 6-month
period.

Hx & PE :
Hx
Directed CV inquiry: function, known DM/CAD/HTN/RF, symptoms of
CAD and CHF.
PHx
Directed CV for CHF, LV and RV compromise, distal perfusion
Directed for Resp: signs of CHF, COPD

Investigations :
CBC and diff, electrolytes, renal function, glucose
Type and screen and crossmatch for 4 units
ABG (on room air) if any concern of preoperative respiratory function
CXR (if any concerns of COPD or CHF)
EKG
CT abdomen (extent and position of the aneurysm)
Refer to the AHA guidelines for non-invasive (stress MIBI, dobutamine Echo)
inquiry. (easy to remember: if two or more of intermediate clinical predictors,
high risk surgery, or low functional capacity algorithm states to get test). See
the end of presentation for the cheat sheet!

Optimization :
Volume resuscitation
Preoperative beta-blocker (AHA guidelines 2006)

Preoperative statin (systematic review in progess)

Renal protection (mannitol)
Continue their preoperative medications (exception: ACEi/ARB)
Management of anticoagulation (if on any)
Judicious anxiolysis (want to minimize sympathetic outflow!)

Options :
Open vs endovascular repair (AHA/ACC 2005 guidelines published in Circulation)
 Open surgical repair was recommended for patients at low or average
risk of operative complications.
 Endovascular repair was suggested in patients at high risk of
complications from open operations.
  Endovascular repair may be considered in patients who are not at high
surgical risk, but evidence of benefit is less well established in this
setting.

Majority of the data comes from the EVAR-1 and DREAM trials which (to
make a long story short) showed decreased 30-day morbidity and mortality with
a stent (especially in high-risk patients) but, the long term f/u showed that
after 1 year this benefit was no longer apparent.

If open: GETA +/- epidural

If epidural: concern with ‘bloody’ placement as the patient will receive heparin
anticoagulation

Setup :
Discuss with the surgeon/view imaging to elucidate whether the X-clamp will
be place: supraceliac, suprarenal, or infrarenal. As a general rule, the more
distal the clamp the less increase of LV afterload.
Routine CAS monitors
Large bore IV access (proximal to X-clamp)
Invasive BP monitor
CVC (can be post-induction) for the delivery of intropes/pressors
PAC/TEE in high risk patients: patients with LV dysfunction or CAD
IV fluid warmer, Bair Hugger (warm proximal to the X-clamp), temperature
probe
Have inotropes and vasodilators mixed and ready to use.
Have syringes of phenylephrine, ephedrine, NTG, nitroprusside and esmolol
ready to use at the time of induction/X-clamping/de-clamping and emergence

Management :
Induction
Prior to induction if the patient is stable place a concordant epidural
Slow titrated induction with anesthetic goals in mind (as long as you
recognize the need to provide blunted response to laryngoscopy while
preserving blood pressure the agents used are less important)

Maintenance
If epidural in-situ question of hypotension if use prior to the removal of
the X-clamp.
Any balanced technique with the hemodynamic goals in mind is
acceptable.

Emergence/Post op
Treatment of coagulopathies
Normalization of temperature
Treatment of anemia
Good postop pain management and anxiolysis to minimize SNS outflow
 Vigilence for postop hypotension/tachycardia/confusion which may be
early signs of postoperative myocardial ischemia
Patient should be in a high dependency unit with EKG monitoring
Monitor U/O for renal insufficiency

Problems :
1. X-clamping hypertension
Recognize that the application of the X-clamp increases MAP
proximally, PAP, PWP, LVESP, LVEDP and decreases the CO.
2. De-clamping hypotension
Blood and fluid loss should be replaced, of normalizing preload
levels before declamping.
The FIO2 should be increased to 100% if the patient is not already
receiving 100% oxygen.
The concentration of inhalation anesthetic agent should be reduced
because it has a potential cardiac depressant effect.
Epinephrine, phenylephrine, sodium bicarbonate, and calcium chloride
should be available just before the release of the clamp, as well as calcium
chloride.
The aortic cross clamp can be gradually released and reapplied or the
aorta compressed manually by the surgeon if significant hypotension occurs.
Attention should be given to coagulation abnormalities in the post–cross-
clamp period.
ABG should be drawn just prior to release and then after release to
ensure optimum Hct and to evaluate the electrolytes.

References

Hirsch, AT, Haskal, ZJ, Hertzer, NR, et al. ACC/AHA 2005 Practice Guidelines
for the management of patients with peripheral arterial disease (lower
extremity, renal, mesenteric, and abdominal aortic): Circulation 2006;
113:e463.

MILLER pg 2070-2071

Shine, T. S. J. and Murray, M.J. Intraoperative management of aortic

aneurysm surgery. Anesthesiology Clin N Am
22: (2004); 289– 305.