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Esposito D, Fargion AT, Dorigo W, Melani C, Mauri F, Zacà S, Pratesi G, Piffaretti G, Angiletta D, Pratesi C, Pulli R. Endovascular aneurysm repair under local anesthesia through bilateral percutaneous femoral access is a safe strategy to improve early outcomes and reduce hospital stay. INT ANGIOL 2024; 43:262-270. [PMID: 38454886 DOI: 10.23736/s0392-9590.24.05134-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND To estimate the impact of anesthetic conduct, alone and in combination with the type of femoral access, on early results after endovascular aneurysm repair (EVAR). METHODS A retrospective multicenter analysis on patients undergoing elective standard EVAR at four academic centers was performed. Patients undergoing the procedure through either local or general anesthesia were compared. Comparative subanalyses of the two groups were performed for the type of femoral access to evaluate further impact on outcomes. RESULTS Five hundred twenty-four patients underwent elective standard EVAR, of which 207 (39.5%) under general anesthesia and 317 (60.5%) under local anesthesia. Patients who underwent general anesthesia had higher 30-day mortality rates (3.4% vs. 0.3%, P=0.005), as well as slightly worse 30-day major systemic complication rates (8.2% vs. 5.4%, P=0.195). There were no differences in terms of reinterventions (2.1% vs. 2.5%, P=0.768) and aneurysm-related mortality (0% vs. 0.4%, P=0.422) at one year. Total intervention times were significantly longer in the general anesthesia group (126 vs. 89 minutes, P=0.001), as well as the total length of hospital stay (7.6 vs. 5.3 days, P=0.007). At subanalyses, the combination of local anesthesia with bilateral percutaneous femoral access further improved 30-day outcomes and determined an additional reduction in total intervention times and ICU stays. CONCLUSIONS EVAR performed under local anesthesia has a significantly better impact on early results when compared to general anesthesia. Combining percutaneous bilateral femoral access to local anesthesia reduced procedural times, ICU stays and consequently improved early results.
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Affiliation(s)
- Davide Esposito
- Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy -
| | - Aaron T Fargion
- Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Walter Dorigo
- Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Caterina Melani
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa School of Medicine, Genoa, Italy
| | - Francesca Mauri
- Unit of Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Sergio Zacà
- Department of Emergency and Organ Transplantation, University of Bari School of Medicine, Bari, Italy
| | - Giovanni Pratesi
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa School of Medicine, Genoa, Italy
| | - Gabriele Piffaretti
- Unit of Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Domenico Angiletta
- Department of Emergency and Organ Transplantation, University of Bari School of Medicine, Bari, Italy
| | - Carlo Pratesi
- Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Raffaele Pulli
- Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Lee S, You C, Kucey A, Alam F, Papia G, Kucey DS, Forbes T, Choi S, Dueck AD, Kayssi A. General versus loco-regional anesthesia for endovascular aortic aneurysm repair. Cochrane Database Syst Rev 2023; 4:CD013182. [PMID: 37052421 PMCID: PMC10100250 DOI: 10.1002/14651858.cd013182.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Aortic aneurysms occur when the aorta, the body's largest artery, grows in size, and can occur in the thoracic or abdominal aorta. The approaches to repair aortic aneurysms include directly exposing the aorta and replacing the diseased segment via open repair, or endovascular repair. Endovascular repair uses fluoroscopic-guidance to access the aorta and deliver a device to exclude the aneurysmal aortic segment without requiring a large surgical incision. Endovascular repair can be performed under a general anesthetic, during which the unconscious patient is paralyzed and reliant on an anesthetic machine to maintain the airway and provide oxygen to the lungs, or a loco-regional anesethetic, for which medications are administered to provide the person with sufficient sedation and pain control without requiring a general anesthetic. While people undergoing general anesthesia are more likely to remain still during surgery and have a well-controlled airway in the event of unanticipated complications, loco-regional anesthesia is associated with fewer postoperative complications in some studies. It remains unclear which anesthetic technique is associated with better outcomes following the endovascular repair of aortic aneurysms. OBJECTIVES To evaluate the benefits and harms of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repair. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search was 11 March 2022. SELECTION CRITERIA We searched for all randomized controlled trials that assessed the effects of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repairs. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were: all-cause mortality, length of hospital stay, length of intensive care unit stay. Our secondary outcomes were: incidence of endoleaks, requirement for re-intervention, incidence of myocardial infarction, quality of life, incidence of respiratory complications, incidence of pulmonary embolism, incidence of deep vein thrombosis, and length of procedure. We planned to use GRADE methodology to assess the certainty of evidence for each outcome. MAIN RESULTS We found no studies, published or ongoing, that met our inclusion criteria. AUTHORS' CONCLUSIONS We did not identify any randomized controlled trials that compared general versus loco-regional anesthesia for endovascular aortic aneurysm repair. There is currently insufficient high-quality evidence to determine the benefits or harms of either anesthetic approach during endovascular aortic aneurysm repair. Well-designed prospective randomized trials with relevant clinical outcomes are needed to adequately address this.
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Affiliation(s)
- Sandra Lee
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Carolyne You
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Andrew Kucey
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Fahad Alam
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Giuseppe Papia
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Daryl S Kucey
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Thomas Forbes
- Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Stephen Choi
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Andrew D Dueck
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Ahmed Kayssi
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Lei J, Pu H, Wu Z, Huang Q, Yang X, Liu G, Lu X. Local versus general anesthesia for endovascular aneurysm repair in ruptured abdominal aortic aneurysm: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2022; 100:679-686. [PMID: 35801490 DOI: 10.1002/ccd.30326] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/29/2022] [Accepted: 06/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/BACKGROUND In the endovascular treatment of ruptured abdominal aortic aneurysm (RAAA), there is no effective evidence to show preference for a specific anesthetic option. A meta-analysis was conducted to assess the result of different anesthesia in endovascular aneurysm repair (EVAR) of RAAA. METHODS Randomized controlled trials (RCTs) and cohort studies were searched in PubMed, Embase, Ovid, and the Cochrane Library. Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool were applied to evaluate the quality of cohort studies and RCTs, respectively. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to express differences for primary and secondary outcomes. Subgroup analyses and sensitivity analyses were applied in the primary outcome to illustrate the results further. Significance was set at p < 0.05. Random-effects models were used considering limited research regardless of I2 < 50%. RESULTS Ten cohort studies were included in this meta-analysis. Perioperative mortality was presented as the primary outcome by analyzing eight of these research. Among the included patients, local anesthesia (LA) was considered as a better choice considering perioperative mortality (n = 156/902) rather than general anesthesia (n = 907/3434) with significant difference (OR: 0.49; 95% CI: 0.35-0.67; p < 0.00001; I2 = 42%). However, no significant difference was found in the secondary outcome: the complication rate, ICU admission rate, postoperative morbidity of pneumonia, myocardial infarction, leg ischemia, and wound complication. CONCLUSIONS There exists some evidence in this review that LA appears to improve perioperative mortality, especially in hemodynamically stable patients and should be recommended for patients undergoing EVAR with RAAA when appropriate.
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Affiliation(s)
- Jiahao Lei
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Hongji Pu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Zhaoyu Wu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Qun Huang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xinrui Yang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Guang Liu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.,Vascular Center of Shanghai JiaoTong University, Shanghai, China
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