Anesthetic Management

Local,^[448] regional,^[449] and general anesthesia^[450] have all been described for endovascular aortic repair. A variety of regional techniques have been used, including spinal, continuous spinal, epidural, and combined spinal and epidural. General anesthesia was commonly used with early-generation devices because procedure times were often long. As centers have gained experience with newer-generation devices, procedure times have been reduced, and local and regional techniques are more often used, most commonly with intravenous sedation. A retrospective analysis of 229 endovascular abdominal aortic aneurysm repairs using local anesthesia with intravenous sedation or general anesthesia reported similar rates of cardiac and pulmonary morbidity. ^[450] Reduced intraoperative fluid requirements ^{[450] [451]} and less vasopressor support^[451] have been reported with the use of local anesthesia. As with open aortic repair, maintenance of vital organ perfusion and function by the provision of stable perioperative hemodynamics is likely more important to overall outcome than is the choice of anesthetic technique.

I most commonly use a general anesthetic technique for endovascular aortic repair, particularly in patients requiring extensive groin dissection or any retroperitoneal dissection and in those requiring complex repairs, during which conversion to open repair may be more likely.

2091

Placement of a radial artery catheter should be routine for all endovascular aortic repairs. I commonly place it on the right side, because a catheter may be placed percutaneously in left brachial artery for aortic angiography. Central venous and pulmonary artery catheter monitoring is not routine. Two large-bore peripheral intravenous catheters are recommended. Although blood loss and fluid requirements are usually not excessive, the potential for rapid blood loss is real. The possibility of acute aortic rupture necessitates the availability of fluids, blood, and a rapid infusion device. Urine output is routinely monitored. Active patient warming is often necessary to prevent hypothermia, particularly with longer procedures.

Endovascular repairs involving the descending thoracic aorta may require additional preparation and monitoring. These procedures are often performed in the operating room under general anesthesia. Although current-generation devices are much less prone to graft migration during deployment, pharmacologic (i.e., sodium nitroprusside or nitroglycerin) induced hypotension (i.e., systolic blood pressure less than 100 mm Hg) is commonly used during deployment. TEE monitoring is often used, and can be extremely helpful in identifying proximal and distal stent-graft landing zones, entry and exit points of dissections, true and false lumens, and aneurysm exclusion. Although published reports of endovascular repairs involving the descending thoracic aorta are limited, neurologic deficits consistent with spinal cord ischemia have been reported.^{[452] [453]} Concomitant or previous abdominal aortic repair and long segment thoracic aortic exclusion appear to be important risk factors.^{[452] [453] [454]} Postoperative hypotension also may play a role.^[453] CSF drainage has been shown to reverse delayed-onset neurologic deficit after endovascular TAA repair,^{[386] [387] [453]} prompting some centers to employ perioperative CSF drainage in all high-risk patients.^[453] Intraoperative spinal evoked potential monitoring and temporary (15 minutes) balloon occlusion of the thoracic aorta before stent-graft deployment has been reported as a means to evaluate the risk of spinal cord ischemia.^[455]