Endovascular aortic repair - Revision history

Asdoyal at 14:57, 12 November 2024

2024-11-12T14:57:40Z

← Older revision		Revision as of 07:57, 12 November 2024
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	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===

			* Arterial catheter and transducer
			* Hotline on fluid warmer
			* Infusion pumps
			* Vasopressor infusions available (usually norepinephrine on pump)
			* Push dose pressors drawn up
			* Heparin and protamine
			* +/- lumbar drain setup
			* Heated circuit (if available)

	===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===		===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===

	*IV midazolam for anxiety		*IV midazolam (+/- Fentanyl) for anxiety
	*PO acetaminophen for pain control		*PO acetaminophen for pain control

	===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===		===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===
	Spinal and/or epidural may be considered for endovascular abdominal aortic aneurysm repair <ref name=":1">{{Cite book\|url=https://www.worldcat.org/oclc/1117874404\|title=Anesthesiologist's manual of surgical procedures\|date=2020\|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu\|isbn=978-1-4698-2916-6\|edition=Sixth edition\|location=Philadelphia\|oclc=1117874404}}</ref>		Spinal and/or epidural may be considered for endovascular abdominal aortic aneurysm repair <ref name=":1">{{Cite book\|url=https://www.worldcat.org/oclc/1117874404\|title=Anesthesiologist's manual of surgical procedures\|date=2020\|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu\|isbn=978-1-4698-2916-6\|edition=Sixth edition\|location=Philadelphia\|oclc=1117874404}}</ref>

			If lumbar drain needed, usually placed by VIR and capped the day prior. When entering the OR, attach the lumbar drain chamber tubing to the lumbar drain before laying the patient down to ensure adequate CSF flow. Once the patient is supine on the OR bed, check again that CSF is freely flowing. At this point, make sure the transducer is zeroed to the level of the subarachnoid space (typically even with the level of the ear).

	== Intraoperative management==		== Intraoperative management==
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	*TEE used to assist in the identification of aneurysm necks, monitor the deployment of the stent graft, endoleaks status post deployment, and aortic dissection (Endovascular Thoracic Aneurysm Repair)		*TEE used to assist in the identification of aneurysm necks, monitor the deployment of the stent graft, endoleaks status post deployment, and aortic dissection (Endovascular Thoracic Aneurysm Repair)
	*Urine output monitoring in the setting of possible renal vessel occlusion from deployment of stent graft and contrast induced nephropathy		*Urine output monitoring in the setting of possible renal vessel occlusion from deployment of stent graft and contrast induced nephropathy
	*Spinal drain monitoring if placed for high risk patient undergoing endovascular thoracic aneurysm stent grafting		*Spinal drain (a.k.a. lumbar drain) CSF draining and pressure monitoring if placed for high risk patient undergoing endovascular thoracic aneurysm stent grafting
	*Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) may be used to assess for spinal ischemia for patient undergoing endovascular thoracic stent grafting<ref name=":0" />		*Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) may be used to assess for spinal ischemia for patient undergoing endovascular thoracic stent grafting<ref name=":0" />
	*At Least 1 large bore IV (14-16G) given risk of vascular injury or rupture		*At Least 1 large bore IV (14-16G) given risk of vascular injury or rupture
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	* Maintenance of baseline MAP as this patient population have increase risk of CVA, MI, aortic dissection, and paraplegia		* Maintenance of baseline MAP as this patient population have increase risk of CVA, MI, aortic dissection, and paraplegia
	*Just prior to stent deployment, BP must be decrease to reduce the risk of graft migration during deployment with vasodilators		*Just prior to stent deployment, BP must be decrease to reduce the risk of graft migration during deployment with vasodilators
	*Post stent graft deployment, BP is increased to ensure perfusion especially if there is a risk of spinal ischemia with ~~vasopressors~~		*Post stent graft deployment, BP is increased to ensure perfusion especially if there is a risk of spinal ischemia with vasopressor
			*Closed loop communication with surgical team regarding heparinization and ACT monitoring
			*'''Spinal cord ischemia is a rare, but devastating complication of both open and endovascular aortic aneurysm repair. Incidence in EVAR has been reported as 0.21%'''<ref>Koda Y, Yamanaka K, Omura A, Gentsu T, Yamaguchi M, Okada K. Spinal cord ischemia after elective endovascular abdominal aortic aneurysm repair in a patient with multiple occlusions of the intercostal and internal iliac arteries. J Vasc Surg Cases Innov Tech. 2022 Jul 9;8(3):447-449. doi: 10.1016/j.jvscit.2022.06.007. PMID: 36016702; PMCID: PMC9395748.</ref> '''and up to 6.9% in TEVAR'''<ref>Toshifumi Hiraoka, Tatsuhiko Komiya, Hiroshi Tsuneyoshi, Takeshi Shimamoto, Risk factors for spinal cord ischaemia after thoracic endovascular aortic repair, ''Interactive CardioVascular and Thoracic Surgery'', Volume 27, Issue 1, July 2018, Pages 54–59, <nowiki>https://doi.org/10.1093/icvts/ivy037</nowiki></ref>
			*'''Remember that spinal cord perfusion pressure is equal to the mean arterial pressure minus the cerebral spinal cord pressure (SCPP = MAP - ICP)'''
			*'''The most common mitigation strategy is blood pressure augmentation (increasing MAP) with MAP goals usually >90'''
			**SCI is multifactorial, but in endovascular repair, it is usually thought to be the result of the permanent interruption, by covering with the stent, of sufficient sources of cord blood supply to render a portion of the cord nonviable - these sources include the segmental arteries, artery of Adamkiewicz, subclavian, and hypogastric arteries - as well as decrease of pressure in those arteries, by major bleeding or other causes of shock<ref name=":03">Randall B. Griepp, Eva B. Griepp, Spinal cord protection in surgical and endovascular repair of thoracoabdominal aortic disease, The Journal of Thoracic and Cardiovascular Surgery, Volume 149, Issue 2, Supplement, 2015, Pages S86-S90, ISSN 0022-5223, <nowiki>https://doi.org/10.1016/j.jtcvs.2014.10.056</nowiki>. (<nowiki>https://www.sciencedirect.com/science/article/pii/S002252231401561X</nowiki>)</ref>
			**Episodes of delayed paraplegia/paraparesis have been reversed by increasing blood pressure and cardiac output. Clearly, both an increase in arterial pressure and a decrease in CSF pressure result in a net increase in perfusion of the spinal cord. Similarly, because central venous pressure and CSF pressure are—at least in part—additive in increasing outflow pressure from the spinal canal, it is important to avoid hemodynamic management strategies that entail high venous pressure<ref name=":03" />
			*Larger grafts will cover more of the arteries that supply the spinal cord and, therefore, increase the risk of ischemia. '''In these higher risk cases, a lumbar drain can be used to drain CSF, lowering the ICP, and, therefore, increasing the spinal cord perfusion pressure.''' Whether CSF drainage improves outcomes is not entirely clear<ref>Wong C S, Healy D, Canning C, Coffey J C, Boyle J R, Walsh S R. A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting. J Vasc Surg. 2012;56(05):1438–1447.</ref>
			**Drainage can be set to an ICP threshold after the drain transducer is "zeroed" to the patients spine (i.e., the drain will drain CSF when the ICP is greater than 12mmHg)
			**Drainage can be set as a volume per hour (i.e., drain 10ml per hour)
			**Overly aggressive CSF drainage carries a risk of intracranial hemorrhage (related to tearing bridging vessels). This risk can be minimized by not draining more than 20ml per hour and/or targeting ICP of 8-10mmHg<ref>Ellauzi H, Arora H, Elefteriades JA, Zaffar MA, Ellauzi R, Popescu WM. Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery-Pros and Cons. Aorta (Stamford). 2022 Dec;10(6):290-297. doi: 10.1055/s-0042-1757792. Epub 2022 Dec 20. PMID: 36539146; PMCID: PMC9767776.</ref>
			*Occasionally (rarely at UNC), somatosensory evoked potentials (SSEPs) and/or motor evoked potentials (MEPs) may be used to monitor for SCI<ref>Cheruku, Sreekanth; Huang, Norman; Meinhardt, Kyle; Aguirre, Marco (2019-12). "Anesthetic Management for Endovascular Repair of the Thoracic Aorta". ''Anesthesiology Clinics''. 37 (4): 593–607. doi:10.1016/j.anclin.2019.07.001. ISSN 1932-2275. <nowiki>PMID 31677680</nowiki>.</ref>
			*Because of its more tenuous blood supply, the anterior two-thirds of the spinal cord are most at risk for ischemia which presents as a painful myelopathy known as anterior spinal artery syndrome

	===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===		===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===
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	*Assessment of hip flexion if spinal cord is at risk for ischemia		*Assessment of hip flexion if spinal cord is at risk for ischemia
	* Reversal of heparin with protamine with confirmation of ACT returning to normal value		* Reversal of heparin with protamine with confirmation of ACT returning to normal value
			*Maintain BP goals

	==Postoperative management==		==Postoperative management==

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:45:43Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:45, 21 February 2022
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	\|Assess baseline functional status and evaluate for myocardial ischemia, previous myocardial infarction, valvular dysfunction, heart failure and peripheral arterial disease.		\|Assess baseline functional status and evaluate for myocardial ischemia, previous myocardial infarction, valvular dysfunction, heart failure and peripheral arterial disease.
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|Assess for COPD, cigarette smoking, and reversible pulmonary pathology.		\|Assess for COPD, cigarette smoking, and reversible pulmonary pathology.

Chris.Rishel: Reorganization

2022-01-18T04:48:49Z

Reorganization

Show changes

Chris.Rishel: Chris.Rishel moved page Endovascular stent grafting of aortic aneurysms to Endovascular aortic repair without leaving a redirect

2022-01-18T04:18:59Z

Chris.Rishel moved page Endovascular stent grafting of aortic aneurysms to Endovascular aortic repair without leaving a redirect

← Older revision

Revision as of 21:18, 17 January 2022

Cornel.Chiu: Chart comparing thoracic and abdominal aortic aneurysms

2022-01-18T02:31:47Z

Chart comparing thoracic and abdominal aortic aneurysms

New page

{{Infobox surgical procedure
| anesthesia_type = General vs neuraxial (endovascular abdominal aortic aneurysm repair) vs rarely, local with MAC
| airway = ETT vs non-invasive O2
| lines_access = PIV x 2 with at least 1 large bore (14-16 G), arterial line (right sided preferred)
| monitors = Standard ASA monitors, 5-lead EKG, arterial line, TEE (endovascular thoracic aortic aneurysm repair)
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Endovascular stent grafting of aortic aneurysm is a surgical procedure by which a stent graft is deployed along the extent of the aortic lesion through vascular access commonly via the common femoral vessels. The stent graft protects the aneurysmal wall from high blood pressure in the aorta decreasing the risk of rupture. This procedure is indicated when aneurysm size is larger than 5.5 cm or if the growth rate of the aneurysm is 10 mm or more per year due to the increased risk of rupture<ref>{{Cite book|url=https://www.worldcat.org/oclc/1280374077|title=Stoelting's anesthesia and co-existing disease|date=2022|others=Roberta L. Hines, Stephanie B. Jones, Robert K. Stoelting|isbn=978-0-323-71861-5|edition=Eighth edition|location=Philadelphia, PA|oclc=1280374077}}</ref><ref name=":0">{{Cite journal|last=Cheruku|first=Sreekanth|last2=Huang|first2=Norman|last3=Meinhardt|first3=Kyle|last4=Aguirre|first4=Marco|date=2019-12|title=Anesthetic Management for Endovascular Repair of the Thoracic Aorta|url=https://pubmed.ncbi.nlm.nih.gov/31677680|journal=Anesthesiology Clinics|volume=37|issue=4|pages=593–607|doi=10.1016/j.anclin.2019.07.001|issn=1932-2275|pmid=31677680}}</ref>. Endovascular stent grafting of aortic aneurysm involves obtaining vascular access to allow introduction of stent deployment apparatus. Prior to introduction of stent deployment apparatus, systemic heparinization is provided. Fluoroscopy is performed with IV contrast to evaluate vascular anatomy and guide stent graft deployment apparatus placement. Once the stent graft is deployed and fluoroscopy/TEE confirmed optimal placement without the presence of endoleak or aortic dissection, stent graft introducer is removed and vascular access sites are closed to obtain hemostasis <ref name=":0" />.

==Preoperative management==

===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Assess for presence of history cerebrovascular disease or carotid stenosis by obtaining baseline neurologic exam especially strength of lower extremities and auscultation
|-
|Cardiovascular
|Assess for presence of myocardial ischemia, previous myocardial infarction, valvular dysfunction, heart failure and peripheral arterial disease. Obtaining baseline EKG and functional status assessment are mandatory. Review diagnostic transthoracic echocardiography (TTE) as most patients have completed as part of their workup. Exercise or pharmacologic stress testing or radionuclide imaging may be warranted in this patient population if there are any abnormal findings.
|-
|Respiratory
|Assess for COPD, cigarette smoking, and reversible pulmonary pathology

Smoking cessation of at least 8 weeks
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|Preoperative hydration and avoidance of nephrotoxic drugs during the perioperative period are important to reduce the risk of kidney injury due to IV contrast used during the procedure.
|-
|Endocrine
|
|-
|Other
|
|}

===Labs and studies===

*Type and screen in the occasion that transfusion is needed
*Contrast-enhanced spiral CT scans of the thorax and thoracic aortography to assess the dimensions of the aneurysms
**This allows for the assessment of adequate proximal and distal neck for surgical planning. The CT scan also helps assess the adequacy of the vessel used for vascular access for the stent introducer system
*EKG to assess for any myocardial ischemia or previous infarction
*TTE to assess valvular disease, size and extent of aneurysm, and LV function

===Operating room setup===

===Patient preparation and premedication===

*IV midazolam for anxiety
*PO acetaminophen for pain control

===Regional and neuraxial techniques===
Spinal and/or epidural may be considered for endovascular abdominal aortic aneurysm repair <ref name=":1">{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>

==Intraoperative management==

===Monitoring and access===

*Standard ASA monitors
*5-lead EKG
*Arterial line is required as it allows prompt vasopressor titration in response to blood pressure change, particularly just prior to stent deployment and post stent deployment
**Right sided preference as left sided vascular access from the surgical team may be needed allowing for an easier approach to the aorta compared to right sided approach. Also, the stent graft may block the L subclavian artery leading to false reading <ref name=":1" />
*TEE used to assist in the identification of aneurysm necks, monitor the deployment of the stent graft, endoleaks status post deployment, and aortic dissection (Endovascular Thoracic Aneurysm Repair)
*Urine output monitoring in the setting of possible renal vessel occlusion from deployment of stent graft and contrast induced nephropathy
*Spinal drain monitoring if placed for high risk patient undergoing endovascular thoracic aneurysm stent grafting
*Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) may be used to assess for spinal ischemia for patient undergoing endovascular thoracic stent grafting<ref name=":0" />
*At Least 1 large bore IV (14-16G) in the situation of bleeding from vascular injury or rupture

===Induction and airway management===

*Most common anesthesia type is general anesthesia
**Standard induction with propofol or etomidate, short acting opioid to blunt sympathetic response, neuromuscular blockade for endotracheal intubation
*If regional anesthesia is chosen, minimal to deep sedation with midazolam, fentanyl, propofol or dexmedetomidine is reasonable.
*Rarely, local anesthetic placement by the surgical team with monitored anesthesia care is implemented depending on patient cooperativity. Minimal to deep sedation is reasonable

===Positioning===

*Supine +/- slight right lateral decubitus (endovascular thoracic aortic aneurysm repair)

===Maintenance and surgical considerations===

*Volatile anesthetics supplemented with opioids for analgesia if neuromonitoring is not used
*If neuromonitoring is used, 0.5 MAC of volatile anesthetic supplemented by IV anesthetic/opioids or TIVA and avoiding neuromuscular blockade after intubating dose
*Administration of heparin

*Verification of activated clotting time (ACT) throughout the case with goal of 200 seconds until introducer is removed <ref name=":0" />
*Maintenance of baseline MAP as this patient population have increase risk of CVA, MI, aortic dissection, and paraplegia
*Just prior to stent deployment, BP must be decrease to reduce the risk of graft migration during deployment with vasodilators
*Post stent graft deployment, BP is increased to ensure perfusion especially if there is a risk of spinal ischemia with vasopressors

===Emergence===

*PONV prophylaxis
*Reversal of neuromuscular blockade if used
*Assessment of hip flexion if spinal cord is at risk for ischemia
*Reversal of heparin with protamine with confirmation of ACT returning to normal value

==Postoperative management==

===Disposition===

*PACU
*Floor
*If any complications requiring ICU, then ICU

===Pain management===

*Postoperative pain is usually mild

*Multimodal pain management
**PO/IV acetaminophen
**PO/IV opioid
**Local anesthetic at vascular access sites
**Epidural analgesia if chosen as anesthetic technique
**Usually avoiding NSAID due to pre-existing renal disease or potential renal injury

===Potential complications===

*Endoleaks
*Vascular injury
*Graft migration
*Stent frame fractures
*Breakdown of graft material
*Spinal cord ischemia or infarction secondary to occlusion of intercostal arteries
*Intra-abdominal ischemia secondary to occlusion of vessels supplying the gastro-intestinal organ including the celiac artery, superior mesenteric artery, inferior mesenteric artery, and renal arteries

*Bleeding from groin site or retroperitoneal bleeding
*Contrast induced nephropathy

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Thoracic Aortic Aneurysms
!Abdominal Aortic Aneurysms
|-
|Unique considerations
|Use of TEE and possible neuro-monitoring and lumbar drain
|
|-
|Position
|Supine +/- slight right lateral decubitus
|Supine
|-
|Surgical time
|1-3 hours
|1-3 hours
|-
|EBL
|Minimal, unless vascular injury
|Minimal, unless vascular injury
|-
|Postoperative disposition
|Usually PACU to the floor, possible ICU
|Usually PACU to the floor
|-
|Pain management
|Multimodal
|Multimodal
|-
|Potential complications
|Paraplegia
|Intra-abdominal ischemia/infarction
|}

==References==

[[Category:Surgical procedures]]
<references />