ANAESTHESIA FOR ENDOVASCULAR SURGERY (TEVAR AND EVAR
• Abdominal abdominal aneurysm(AAA) are largely an incidental discovery during investigation of backache,hip pain or urinary tract complaints. • Men:Woman 5:1 • Surgery recommended when AP diameter >55mm • Risk of spontaneous rupture depends on size : <1% per annum for AAA <55mm to >17% for AAA>60mm.
• 1/3 of AAA have anatomical features suitable for endovascular repair. • Endovascular surgery – less invasive • EVAR grown in popularity since 1990s. • Aortic stent graft passed via femoral/iliac arteries under fluouroscopic guidance through aortic lumen to tightly fit above and below AAA. • Stent cuts off systemic circulation from aneurysmal sac causinf sac to clot off or shrink with time.
• • • • • • • Minimally invasive Reduces blood loss (upto 60% less) Reduced stress response No aortic cross clamp necessary 30 day survival advantage Earlier ambulation with less pain Shorter hospital stay (50%) with less strain on ICU beds
• No different from a patient for open AAA repair • Patients: Elderly Limited cardiorespiratory reserve High prevalence of CAD (pts assessed using AHA guidelines and EVAR falls in intermediate risk) • Renal function must be assessed carefully as there is a risk of contrast induced nephropathy(CIN). Methods of reducing CIN are: -generous peri-op fluids - minimal use of contrast - increasing interval betweed contrast Ct angiography and EVAR - prophylactic use of antioxidants like N-acetylcysteine.
• Patients should be seen in Anaesthetic Clinic. If possible patients should be discussed with anaesthetist in charge of the list to avoid last minute cancellations. • Anti-platelet (Clopidogrel) should be stopped 710days prior to surgery. • Aspirin can be continued before surgery. • Consent for anaesthesia taken with possibility of risks in case of conversion to open procedure explained.
• Patients prepared as per for open procedure (risk of conversion is 2%) • Monitoring (ANZCA standards): - Arterial line essential. Placed on the right hand as surgeons may require access to left axillary artery if femoral artery is difficult. - CVP rarely necessary – exception in patient with significant co-morbidities
- CBD necessary in order to monitor urine output as large amount of contrast used - Forecd air warming blanket – maintained above nipple line • Abdominal EVAR can be done under regional anaesthesia where in CSE is more appropriate (bearing in mind Heparin usage intra-op)
• Thoracic EVAR should be done under GA. • IV Heparin 3000U usually given once femoral arteries exposed • For patients under GA, anaesthetist will be asked to suspend resp during digital subtraction angiography is performed. • Blood loss is 60% less and only 12% require blood transfusion. Care taken to examine concealed bleeding from femoral puncture sites.
• In cases of grafts which require balloon expansion, SBP should be maintained 80mmHg as a higher BP will cause stent to be displaced. • Patients should be well hydrated due to the amount of contrast used. Evidence does not suggest the use of diuretics prevents CIN. • In TEVAR, surgeon may request for a CSF drain with CSF pressure monitoring.
• CSF pressure ideally should be maintained <15mmHg ; if higher, CSF should be aspirated. • All lumbar drains should be kept for 48hrs as neurological deficits occur during this period.
• Patients should be nursed in an environment where arterial BP can be monitored. • Hourly urine output necessary in view of CIN • Most abdominal EVARs are stable enough to be nursed in the acute cubicle of the ward. • Several studies have shown that hospital and ICU/HDU stay is reduced by 50% in EVAR patients.
• Strict BP monitoring – keep within 20% of patient’s baseline as there is a risk of graft migration. • Monitoring of CSF pressure via lumbar drain. In event of a bloody tap, surgery will be delayed for 2hrs due to intra-op Heparin usage and associated risks of spinal/epidural hematoma.
• Monitoring neurology – in event of neurological deficits, MAP should be increased with inotropes/pressors and CSF drained. Most neurologies are transient. • Significant number will require coverage of Left subclavian artery stroke/upper limb ischaemia. Urgent carotico-subclavian bypass will be performed.
• All TEVARs require ICU • No anti-coagulants except Aspirin or Clexane will be started in ICU in view of the lumbar drain
1. Endoleak -Persistent blood flow outside an endovascular graft but within the aneurysmal sac. - Immediate or delayed. - Incidence 18% 2. Maldeployment or Malposition of graft.
3. Post- implantation Syndrome - Fever,raised C-proteins and TWC in absence of infection
4. Rupture of iliac artery - more common in females due to smaller calibre of arteries and presents as refractory hypotension. - may require additional stent or conversion to open repair.
5. Stent Graft Limb Thrombosis - occurs within 24hrs and presents as lower limb ischaemia 6. Medical complications - ACS,ARF,CCF,Arrythmias,DVT,CVA,Resp infection