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ANESTHETIC CONSIDERATIONS

FOR ENDOVASCULAR

AORTIC REPAIR IN THE

HYBRID OPERATING ROOM

Peggy Contrera CRNA, MSN

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Topics for Endovascular Aortic Repair

� Review natural history and pathophysiology of aneurysms

� Abdominal aortic aneurysms

� Thoracic and thoracoabdominal aneurysms

� Endovascular surgical options

� Anesthetic considerations

� Hybrid OR

� Anesthetic management

� Outcomes and evolving strategies

4444 Natural History & Pathophysiology

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When is the Aorta Considered Aneurysmal?

� Enlargement of the aorta 1.5 x’s normal

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Types of Aneurysms

� All 3 layer (intima, media and adventitia)

� Spindle-shaped

� Dilate the entire circumference of the vessel wall

� Associated with atherosclerotic or collagen vascular disease

� More common

� Affect longer segments

� Contained Rupture-Confined to an isolated segment

� Localized dilation does not contain all 3 layers of the vessel wall

� Connective tissue, clot or surrounding tissue makes up part of the wall

� Produce a localized outpouching (saccularaneurysm)

Fusiform (True) Pseudoaneurysm (False)

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Abdominal Aortic Aneurysms

� 200,000 new AAA’s dx, 45,000 undergo surgical repair

� Incidence has been � since the 1970’s

� > 15,000 deaths/year in US – 8000 d/t rupture

� Men > women

� Prevalence �’s with age� 1-4% in males > 50 y.o.

� 5% in males > 60 y.o.

� 9% in males > 65 y.o.

� 12.5% in males 75-85 y.o. (5.2% women)

� Caucasian > African American

� 95% of AAA are infrarenal

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Risk Factors for AAA

� History of smoking

� Atherosclerosis

� Adventitial elastin and collagen degradation by proteases

� Family history of aortic aneurysm

� High blood pressure

� High cholesterol

� Male gender

� Advanced age

� Trauma

� Inflammatory vasculitis

� Inherited connective tissue disorders: Marfan’s or Ehlers-Danlos syndrome

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Perioperative mortality from elective resection of infrarenal AAA

� 1950s�18% to 20%

� 1960s� 6% to 8%

� 1970s�5% to 6%

� 1980s�2% to 4% then plateaued

� Hertzer 1989-1998, 1135 consecutive elective AAA�1.2% vs. national rates of 2-4%

� Regionalization of care vs. technological improvements

� Ruptured AAA� Mortality stable at 50% over 4 decades

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Risk of Rupture

� Most are asymptomatic and discovered incidentally

� Law of LaPlace: T = P x R

� Risk of rupture AAA:

� 0% in aneurysms < 4.0 cm in diameter

� 0.5 - 5% � 4.0 to 4.9 cm in diameter

� 3 - 15 % � 5.0 to 5.9 cm in diameter

� 10 - 20 %� 6.0 to 6.9 cm in diameter

� 20 - 40 %� 7.0 to 7.9 cm in diameter

� 30 - 50 %� ≥8.0 cm in diameter

� Aneurysm growth per year O.19-0.35 depending on size

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Medium Sized Aneurysms

� Watch and Wait

� Aneurysms 3.0 - 4.0 cm � ultrasound every 2 to 3 years

� Aneurysms 4.0 - 5.4 cm � ultrasound/CT every 6 – 12 months

� Medical therapy

� Smoking cessation

� Beta blocker therapy

� Possible benefit on aneurysm expansion

� Preferred drug for the treatment of hypertension or angina

� Effectiveness judged by the heart rate response (goal HR 50-60)

� Statins

� ACEI, ARB

� Doxycycline� Matrix metalloproteinases (MMPs) suppresses proteinases involved in extracellular matrix degradation

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Rupture is Catastrophic!

� Rupture into the retroperitoneum � periaortic hematoma

� Classic triad of symptoms

� Severe abdominal or back pain� flank or groin

� Tender pulsatile abdominal or flank mass

� Hypotension or loss of consciousness

� Other presentations: visceral or lower extremity ischemia

� Mortality

� Pre-hospital �30% to 50%

� Pre-surgery� 30% to 40%

� Operative mortality �40% to 50%

� Reduced with endovascular repair vs. open

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Thoracic and Thoracoabdominal Aneurysms

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Bonow (2011): Braunwald's Heart Disease - A Textbook of Cardiovascular Medicine, 9th ed

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Thoracic Aortic Aneurysms

� Much less common:10.4 per 100,000 person-years

� Ascending 60%

� Descending 35%

� Arch

� Occur equally between men and women

� Prevalence increases with age

� Associated with HTN

� Inherited connective tissue disorders including Marfan’s, Loeys-Dietz and Ehlers- Danlos syndromes

� Inflammatory diseases including Takayasu or Giant Cell arteritis, syphilis

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Symptoms of TA or TAA

� Most are asymptomatic and discovered incidentally

� Compression of the trachea, bronchi or esophagus�Hoarseness (compression of recurrent laryngeal nerve)

�Wheezing, coughing, hemoptysis, stridor, dyspnea, dysphasia

� Compression of SVC or innominate� Facial plethora and edema

� Fever with inflammatory disease or mycoticaneurysms

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Crawford Descending Thoracic and Thoracoabdominal Classification

� Type I: � Descending thoracic aorta

� Upper abdominal aorta

� Type II� Descending thoracic aorta

� All or most of the abdominal aorta

� Type III: � Lower portion of the descending thoracic aorta

� Most of the abdominal aorta

� Type IV: � All or most of the abdominal

aorta, including the visceral segment

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Diagnosis of Thoracic Aneurysm

� Traditionally angiography� CT, MRI, TEE� CTA or 3D MRA especially helpful

�Defines eligibility for TEVAR�Stent sizing (many are custom designed)

� Indications for surgery�Diameter

�> 5.5cm ascending�> 6.5 cm for descending � Expanding > 0.5 cm/yr.�Marfan or connective tissue disease 4-4.5 cm

�Symptomatic patients (chest or back pain is a predictor for rupture)

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Aortic Dissection or Rupture

� Natural history of untreated TA �5-year survival 10-20%

� Survival < 10% if rupture

� If elective intervention, survival is 60-79%

� Males 2-4x’s more frequent than females

� Sudden onset of chest or back pain

� Aortic insufficiency with ascending aneurysms

� Embolism, stroke, mesenteric ischemia, renal insufficiency, limb ischemia

� Classified according to its duration� Acute when present for < 2 weeks

� Chronic when present for > 2 weeks

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Risk Factors for Aortic Dissection

� Hypertension

� Genetically triggered thoracic aortic disease

� 1/5 will have 1st degree relative with thoracic disease

� Congenital diseases or syndromes

� Atherosclerosis (penetrating atherosclerotic ulcer)

� Trauma, blunt or iatrogenic

� Cocaine use

� Inflammatory or infectious disease

� Pregnancy

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Acute Aortic Syndromes21

A Classic aortic dissection

B Rupture of the vaso vasorumcausing intramural hematoma

C Penetrating atherosclerotic aortic ulcer

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Aortic Dissections

� Pressure of the pulsatile blood within the aortic wall after dissection � to extension of the dissection

� Dissections usually propagate in an antegrade direction related to the pressure pulse from the aortic blood, but occasionally extend in a retrograde direction

� Dissection flap may be localized or may spiral the entire length of the aorta

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Thoracic Dissecting Aneurysm

� Classification and prevalence by location

� Descending thoracic or thoracoabdominal (60-70 y.o.) >

� Ascending Aortic (50-60 y.o.) >

� Aortic Arch

� The morbidity and mortality rates of acute dissection are highest in the first 2 weeks, especially within the first 24 hours

� >6 cm in diameter � � of rupture

� 1990’s� 13% of patients had elective surgery with 23.7% mortality � 19% had emergency surgery for ruptures with 52% mortality

� Today mortality for an elective open procedure at a center of excellence has � to 3-10%

� TEVAR has potential to improve these stats

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Acute Aortic Dissections25

Bonow (2011): Braunwald's Heart Disease - A Textbook o f Cardiovascular Medicine, 9th ed

26262626 Endovascular Stents and Repair

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What are Endovascular Stents?

� Fabric or synthetic tube grafts reinforced by a wire frame

� Can be collapsed within a catheter for delivery

� Graft is either self-expanding or a ballooning catheter is used to expand the graft

� Designed to span the length of the aneurysm and exclude blood flow into the aneurysm cavity

� Interrupts disease progression and reverses the natural hxresulting in shrinkage of the aneurysmal sac around the stent

� In aortic dissections, the area of the primary tear is covered so that flow is redirected to the true lumen

� Thrombosis of the false lumen

� Aortic remodeling

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True and False Lumen, Before and After Repair

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Endovascular Terminology

� EVAR: EndoVascular Aortic Repair

� EVAAR: Endovascular abdominal aortic repair

� TEVAR: Thoracic endovascular aortic repair

� FEVAR: Fenestrated endovascular repair

� Type of stent graft with holes for critical vessels used primarily for EVAAR

� Branched FEVAR

� Type of stent graft that has branches used primarily for EVAAR

� Aortic debranching: Procedure where critical aortic abdominal or arch vessels are removed from their origin attachment to the aorta and re-routed by anastomosis with another vessel to allow placement of a stent graft

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Potential Advantages of EVAR Over Open Surgical Repair� Less surgical transgression

� Less blood loss

� Fewer transfusions

� Less fluid shifts

� Less hemodynamic perturbations

� Less distal tissue ischemia

� Less end-organ damage

� Less aggressive anesthetic management

� Less cardiovascular stress intra-op

� Fewer complications

� Cardiac

� Pulmonary

� Renal

� Shorter recovery times

� Lower cost

� Lower mortality

� May be suitable for patients otherwise considered “inoperable”

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Basic Procedure

� Groin incision to obtain large-bore femoral arterial access

� Position Collapsed Stent-Graft into Aorta using angiography, IVUS, TEE

� Deploy Stent-Graft

� Seal Ends

� +/-Thrombosis of vessels that feed aneurysm sac

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Stent Evolution

� 1st stents were tubular

� Angioplasty balloon used to fix the stent to the arterial wall

� 2nd stent used to fix distal end

� Tended to migrate

� Aorto-mono-iliac

� Coil occlusion of L Iliac

� Fem-fem bypass

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Today

� Grafts

� Unibody or modular

� Woven polyester (Dacron) or Polytetrafluoroethylene

� Skeleton (stainless steel, nitinol or Eligiloy)

� Self-expanding

� Body is introduced with ipsilateral long limb and contralateral short limb

� A limb extender is deployed into contralateral iliac artery

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Retroperitoneal Approach34

Retroperitoneal incision to access the right common iliac artery

Dacron conduit attached to the right common iliac artery brought out below through a separate incision

http://emedicine.medscape.com/article/1384667-overview#showall

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The Talent

Thoracic Stent

Graft System. The

proximal (A) and

distal (B)

components.

(C, D) The

deployment

technique using

the self-contained

Xcelerant

delivery system,

which allows for

controlled

ratcheted

deployment

initially (C) and

fast ‘‘zip’’

deployment (D).

� Surg Clin N Am 89 (2009) 895–912

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Surg Clin N Am 89 (2009) 895–912

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Aortic Pathology Amenable to Endovascular Repair (Ever-Expanding)

� Symptomatic (any size)

� Asymptomatic

� > 5cm (2x’s normal)

�Growing > 0.5 cm/6 mo

� ↑ Physiologic risk d/t

co-morbidities

� Symptomatic (any size)

� Asymptomatic > 5.5 cm

� Penetrating Atherosclerotic Ulcers

� Type B Aortic Dissection

� Traumatic Aortic Injuries

� Ruptured TAAA

� Fistulas (Aorto-enteric or Aorto-bronchial)

Abdominal AneurysmsDescending Thoracic and

Thoracoabdominal Aneurysms

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EVAR Anatomic Eligibility(Determined by Imaging)� Proximal landing zone (aneurysm “neck”):

� Length: > 15 mm

� Diameter: < 30 mm

� Angulation: < 60 degree angulation in long axis (tortuaosity)

� Thrombus: < than 2 mm layer of mural thrombus

� Distal landing zone: Adequate diameter and length

� Lack of indispensable unstentable branch arteries

� Iliac arteries: Absence of aneurysms and occlusive disease

� Access arteries: Adequate diameter, absence of occlusive disease

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What if the Aneurysm Includes Critical Vessels?

� Hybrid Procedures : combine traditional and endovascular approaches to assure branch perfusion

� Types of Hybrid Procedures

�Direct fixation approach:

� Stent graft device is delivered and deployed into a good landing zone on one end

� Visceral vessels are attached to the aortic graft using branches, fenestrations or both

� Debranching approach:

�Origins of the branch vessels are re-routed to another position via bypass or transposition

� Segment of aorta is covered with a stent graft device

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Aortic Visceral Debranching

� Allows for endovascular stenting of AA that involve major visceral branches (celiac, SMA, renals, IMA)

� Can be performed just before EVAR or as a first part of a “staged” procedure

� Requires a midline laparotomy and systemic heparinization to a goal ACT >300 seconds

� A custom designed fenestrated or multibranched graft with distal anastomoses to the left renal artery, SMA, celiac axis, and right renal artery

� Inflow for visceral debranching is typically performed via a single proximal anastomosis from L iliac, infrarenal aorta or existing infrarenal aortic graft

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Branch Grafting

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Branch Grafting

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Figure 2. Completion CT scans post procedure. (A) A rterial contrast phase reconstruction of a type II thoracoabdominal aneurys m after repair with a 4-branch reinforced fenestrated device. (B) Noncontra st images reconstructed to demonstrate the in vivo appearance of a stent gr aft used to treat a type III thoracoabdominal aneurysm using composite device des ign with a helical celiac branch (purple arrows) and 3 reinforced fene strated branches (green arrows). Roselli, The Journal of Thoracic

and Cardiovascular Surgery ●

Volume 133, Number 6

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Markers are clearly visualized in MIP view ofright renal artery origin (Red arrows

Abdominal aorta after fenestratedendograft procedure

Endovascular aneurysm repair using branched or fenestrated devices Roy K. Greenberg, M.D.

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Aortic Visceral Debranching

� A. Trifurcated Dacron graft used to bypass L renal, SMA, and R renal end to end

� Celiac end to side

� All aortic side branches are ligated at origin (to prevent endoleak)

� TAAA is deployed covering origins of mesenteric and renal arteries

� B. 4-branch with all end to side anastomosis

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J Thorax Cardiovasc Surg 2008;136:21-28

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Mesenteric Debranching

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� A. Debranching of visceral vessels with infrarenal aortic replacement. The aortic-left renal bypass originates from the infrarenal graft (thin arrow), and a bifurcated graft (also originating from the infrarenal graft) was used to bypass the celiac area and superior mesenteric artery (thick arrow).

� B. Posterior view of hybrid procedure with arrows pointing to aortic-renal grafts originating from the infrarenal graft

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Anesthesiology Clin 26 (2008) 481–499

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What if the Aneurysm Includes Critical Head Vessels?

Carotid-subclavian artery bypass created prior to stent-graft placement.(a) Digital subtraction angiogram (DSA) shows a descending thoracic artery aneurysm less than 15 mm from the LSA. (b) Drawing of bypass (arrow) that was created between the left common carotid artery and the LSA.(c) DSA shows a stent-graft that has been positioned over the origin of the LSA. (d) DSA obtained after stent-graft deployment demonstrates complete exclusion of the aneurysm.

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Debranching Aortic Arch48

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Elephant Trunk

50505050 Anesthetic Considerations

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Hybrid OR- Expensive Investment52

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Hybrid OR54

Hybrid Operating Room

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Newer Imaging Devices55

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Yield Better Images(In real-time with less contrast)

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But Present Real Challenges and Hazards in the Hybrid OR

� C-arm can spin 2 revolutions in 8 seconds

�Operator is focused on the image not the patient!

� Potential for injury to patient, equipment, anesthesia and surgical personnel

� Low lying imaging screens �potential for serious head injury!

� Cords across floor � Trip and fall

� Increased exposure to radiation

� Patient

� Surgical personnel

� Anesthesia providers are at highest risk!

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� Personnel stand near patients for long times, and angulated geometries with C-arm equipment may result in high personnel doses from backscatter

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(J Vasc Surg2011;53:885-94.)

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Risk of Radiation Exposure is Real!!

� So Tara Mastracci told me this morning that a preliminary analysis of the data obtained to measure cumulative radiation dose in ORs 76 and 77 has been performed, and by far and away the people who receive the highest doses are the anesthesia team

� And, what I mean when I say by far and away is that the dose to the anesthesia team is anywhere between 10 and 50 times higher than the surgeons

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Protect Yourself!

� Distance

� 2 steps back� ↓ radiation exposure by factor of 4

� 3 steps � ↓ radiation exposure by factor of 9

� Shielding

� A protective lead apron attenuates approximately

90% of scatter radiation

�Mobile shields

� Thyroid shields

� Leaded eyeglasses and gloves

�Wear dosimeter at collar level

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Environment has PAINFUL Aspects!

� Lead aprons are heavy and awkward (especially after

13+ hrs.). Associated with orthopedic problems in interventional community

� All lines, hoses, tubing, wires and body parts must be kept free from C-Arm (remember it spins)

� Hitting head or tripping on equipment is an ever present

danger

� Frequently asked to hold ventilation

� Blood loss

� Insidious and concealed under drapes

� Sudden and dramatic

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Pre-anesthetic assessment

� High incidence of co-morbidities

� Hypertension

� Coronary artery disease

� Cerebrovascular disease

� Diabetes

� Renal disease

� COPD

� High risk surgery (perioperative risk of major cardiac event >5%)

� Patients should undergo functional testing per ACC/AHA criteria

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Preoperative Risk Reduction

� Assessment and optimization of CAD and LV function

�β-Blockers, Statins

�BP Control

� Chronic ACEI/ ARB

� Acute SNP/NTG

� Appropriate treatment of COPD

� Assess carotid disease

� Optimize renal/fluid status

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Pre-anesthetic Assessment

� Prior CVA/TIA� CT or TEE to ID mobile atheroma

� PVD are at � risk of vascular injury and bleeding� Large bore IV access and blood available

� High risk of Acute Kidney Injury (AKI)�Hypoperfusion

�Mechanical encroachment of stent on renal vessels

� Renal emboli

� Patients with pre-op renal insufficiency (creatinine>1.5 or GFR of ≤ 60) are at especially high risk

�4x’s more likely if patient has preexisting dysfunction

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AKI- Risk Reduction Strategies

� Ensure perioperative euvolemia

� Maintain cardiac output and blood pressure

� Limit contrast dye exposure and sub IVUS whenpossible

� Use iso-osmolar non-ionic contrast dye

� Pharmacologic strategies especially in patients with baseline chronic kidney disease:

�N-Acetylcysteine (mucomyst)

�Hydration with sodium bicarbonate/mannitol containing solution

� Statin drugs

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Extra Considerations for FEVAR and TEVAR

� Thoracic Aorta is a more hemodynamically hostile environment than the abdomen

� As procedures become more complicated (multiple branch grafts)

� Longer surgical times

� More puncture sites and catheters

� Blood loss increases (hidden)

� Greater dye load

� Cases requiring a conduit for device delivery require a more dense anesthetic (or higher level RA)

�More post op pain

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Considerations for FEVAR and TEVAR

� Need for transient cessation of blood flow

�Adenosine, overdrive ventricular pacing

� Risk of cerebral emboli

� Limited availability of FDA approved/commercial devices

� Lack of long-term follow-up

� Prior AAA or stent covering T6� diaphragm are at �risk of spinal cord ischemia

� Spinal Drain

� SSEP or MEP

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Spinal Cord

� 2 posterior spinal arteries

� 1 anterior spinal artery

� Internal iliac, middle sacral, inferior mesenteric

� Radicular branches of the intercostals

� Artery of Adamkiewicz

� Arises T9-T12 (T5 -L5)

� SC perfusion pressure = MAP – CSF Pressure

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Risk of Spinal Cord Ischemia

� Paraplegia 1-8%

� Increased risk � Biggest factor is the amount of collateral circulation that is sacrificed

� Extent of the aorta covered by the graft� Critical intercostals T6-T12 supply anterior spinal artery

� Previous AAA (compromised pelvic and hypogastriccollaterals to anterior spinal artery)

� Hypotension

� Severe atherosclerosis of the thoracic aorta

� Injury to external iliac artery

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Choice of Anesthetic

� Consider surgical and patient factors

� General

�Most common (surgeon and patient request)

� Complicated long procedures (TEVAR or FEVAR)

� Procedures lasting > 2hrs

�Need for retroperitoneal access

� TEE, SSEP, MEP

�Need to attain a motionless field for deployment (adenosine or transvenous pacing)

� Difficult airway

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Choice of Anesthetic

� Regional with sedation� Both spinal and lumbar epidural can be used effectively� Epidural may have advantage of dose titration to avoid sympathectomy and allow postoperative neurologic exam

� No contraindications to central neuraxial blockade, e.g.: patient approval, patients not on anticoagulation or platelet inhibitors (thienopyridines)

� MAC with Local� Patient is able to lay in the supine position for 1-2 hours � Patient cooperation and understanding that a “deep MAC” is not be feasible (need for periodic breath holding during angiography)

� Should not reduce the level of monitoring

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Comparing Anesthetic Techniques

� 6009 elective EVAR procedures from the American College of Surgeons National Surgical Quality Improvement Database- J. Vasc. Surgery 2011

� 4868-General

� 419-Spinal

� 331- Epidural

� 391 local/MAC

� Findings: General was associated with

� ↑ Pulmonary morbidity

� ↑ LOS (10% vs. spinal and 20% vs. local)

� ? Selection bias

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Lines and Monitoring

� ECG with automated ST

� R radial A-line (left brachial often used for surgical access)

� 1-2 PIV 16g or larger

� Depending on the extent of the aneurysm

� Central access with large bore multiple access catheter

� Femoral A-line

� CSF pressure

� BIS

� SSEP, EEG (limit inhalation to ½ MAC, avoid hypothermia)

� MEP (limit inhalation, avoid muscle relaxant, avoid hypothermia)

� TEE

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Anesthetic Goals in EVAR

� Maintain hemodynamic stability, and preserve perfusion to vital organs including the brain, heart, spinal cord, kidney and splanchnic vessels

� Avoid imbalance in myocardial oxygen supply/demand relationship and avoids the resultant ischemic acute coronary events

� Reducing dp/dt in patients with both aortic aneurysms and dissections (avoidance of HTN and tachycardia)

� Maintenance of intravascular volume and early identification and management of bleeding

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Causes of Intraop Hypotension

� Absolute hypovolemia due to surgical bleeding

� Relative hypovolemia due to lactic acidosis

� Cardiogenic due to ischemia or dysrhythmias

�Neurogenic due to anterior spinal artery syndrome

�Distributive due to 3rd spacing

� Iatrogenic due to surgical manipulation

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Hemodynamic Manipulation during Aortic Endograft Deployment

� Temporary � in MAP and heart rate during stent deployment to prevent “wind-sock effect”

� Goal is to � cardiac output (CO) in the aorta during deployment until maximum expansion and sealing of the endograft

� The titrated use of short acting agents to

� ↓ heart rate a target heart rate of 50-60 beats/min and MAP to 60 -70 mmHg

� Adenosine 6-18mg IV push gives brief asystole

� Overdrive pacing (180-220bpm) of RV provides predictable cessation aortic blood flow

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Complications: Endoleaks

Type I: Incompetent

proximal or distal

seal

Type II: Backflow

from collaterals

Type III:

Disassociation where

modular components

overlap

Type IV: leaks

through porous graft

of fabric

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N Engl J Med 358:494, 2008.

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Type I Endoleak

� Due to incompetent seal at proximal or distal attachment site

� 0-10%

� Causes:� Undersizing� Heavy aortic calcification

� Immediate or delayed

� Must be repaired as soon as discovered� Proximal or distal graft extension� Embolization� Secondary endograft� Open repair

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Type II Endoleak

� Due to flow into and out of aneurysm from patent branch vessels

� Most prevalent 10-25%� Patent lumbars or inferior mesenteric artery

� Post procedural CT� Spontaneous resolution in 30-100%

� Rx indicated if aneurysmalsac expands or if leak persists >6 months� Laparoscopic clip application

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Type III Endoleak

� Much less common� Type III due to graft defect resulting in separation of graft components or tears in graft fabric� Repaired using additional graft

� Open repair

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Type IV Endoleak and Type V Endoleak or Endotension

� Type IV due to egress of blood through the graft fabric� Usually resolve spontaneously

� Type V- Endotension: Systemic pressure in aneurysmal sac w/o evidence of endoleak� Probably related to inability to capture leak on imaging

� Secondary endograft�Open repair

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Device Migration

� Major cause of 2° intervention

� May cause endoleak, aneurysm expansion and rupture

� Caused by proximal neck dilation d/t

� Continued aneurysm degeneration

�Graft oversizing at insertion

� Migration rates are somewhat device

dependent and � over time

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Abdominal Endograft Limb Thrombosis

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Outcomes EVAAR

� Meta-analysis of 9 recent studies � Cardiac complications� 3% vs. 11%

� Pulmonary complication� 4% vs. 13%

� Renal complications� 5% vs. 8%

� Hospital LOS 3.9 days vs. 10.3 days

� ICU stay 0.5 days vs. 3.9 days

� Long term EVAR did not improve aneurysm-related or all-cause mortality or health-related quality of life

� EVAR substantially increased cost

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TEVAR

� Met-analysis 5888 elective open vs. TEVAR

� � early mortality but no difference beyond 1 year

� � postoperative complications

� Paraplegia 1.9 vs. 4.9%

� Renal Insufficiency 5.9 vs. 15.7%

� Reoperation for bleeding 0.01 vs. 6.5%

� Pneumonia 15.9 vs. 28.7%

� � LOS

� There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year

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J Am Coll Cardiol 2010;55:986–1001

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Experience Counts!

� Experienced surgical teams have fewer complications than inexperienced ones

�Mortality was 40% less in patients treated by experienced teams

� Adverse events necessitating a second procedure were 68% less likely for experienced teams

� Risk of rupture was 8 times less likely for experienced

teams

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The influence of team experience on the outcomes ofendovascular stenting of abdominal aortic aneurysms.Laheij, van Marrewijk, Harris and EUROSTAR. Eur J VascEndovasc Surg 24:128-133 (2002) 2863

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Cleveland ClinicHeart and Vascular Institute

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Cleveland Clinic Experience91

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Thank You!

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