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DeHaven C, Zil-E-Ali A, Lavanga E, Flohr TR, Krause K, Rossip M, Aziz F. Octogenarians fare better under local anesthesia for elective endovascular aortic aneurysm repair. J Vasc Surg 2024; 79:1079-1089. [PMID: 38141740 DOI: 10.1016/j.jvs.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE With an aging patient population, an increasing number of octogenarians are undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) in the United States. Multiple studies have shown that, for the general population, use of local anesthetic (LA) for EVAR is associated with improved short-term and long-term outcomes as compared with performing these operations under general anesthesia (GA). Therefore, this study aimed to study the association of LA for elective EVARs with perioperative outcomes, among octogenarians. METHODS The Vascular Quality Initiative database (2003-2021) was used to conduct this study. Octogenarians (Aged ≥80 years) were selected and sorted into two study groups: LA (Group I) and GA (Group II). Our primary outcomes were length of stay and mortality. Secondary outcomes included operative time, estimated blood loss, return to operating room, cardiopulmonary complications, and discharge location. RESULTS Of the 16,398 selected patients, 1197 patients (7.3%) were included in Group I, and 15,201 patients (92.7%) were in Group II. Procedural time was significantly shorter for the LA group (114.6 vs 134.6; P < .001), as was estimated blood loss (152 vs 222 cc; P < .001). Length of stay was significantly shorter (1.8 vs 2.6 days; P < .001), and patients were more likely to be discharged home (LA 88.8% vs GA 86.9%; P = .036) in the LA group. Group I also experienced fewer pulmonary complications; only 0.17% experienced pneumonia and 0.42% required ventilator support compared with 0.64% and 1.02% in Group II, respectively. This finding corresponded to fewer days in the intensive care unit for Group I (0.41 vs 0.69 days; P < .001). No significant difference was seen in 30-day mortality cardiac, renal, or access site-related complications. Return to operating room was also equivocal between the two groups. Multivariate regression analysis confirmed GA was associated with a significantly longer length of stay and significantly higher rates of non-home discharge (adjusted odds ratio [AOR], 1.59; P < .001 and AOR, 1.40; P = .025, respectively). When stratified by the New York Heart Association classification system, classes I, II, III, and IV (1.55; P < .001; 1.26; P = .029; 2.03; P < .001; 4.07; P < .001, respectively) were associated with significantly longer hospital stays. CONCLUSIONS The use of LA for EVARs in octogenarians is associated with shorter lengths of stay, fewer respiratory complications, and home discharge. These patients also experienced shorter procedure times and less blood loss. There was no statistically significant difference in 30-day mortality, return to operating room, or access-related complications. LA for octogenarians undergoing EVAR should be considered more frequently to shorten hospital stays and decrease complication rates.
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Affiliation(s)
- Christopher DeHaven
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Penn State University College of Medicine, Hershey, PA.
| | - Elizabeth Lavanga
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Tanya R Flohr
- Division of Vascular Surgery, Penn State University College of Medicine, Hershey, PA
| | - Kayla Krause
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Maxwell Rossip
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State University College of Medicine, Hershey, PA
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Batista S, Ferreira MY, Borges J, Oliveira LDB, Slawka E, Bertani R, Besborodco RM, Bocanegra-Becerra JE, Oberman DZ, Almeida Filho JA. Safety of local anesthesia in endovascular treatment of Aneurysms: A systematic review and Meta-Analysis. J Clin Neurosci 2024; 123:47-54. [PMID: 38531194 DOI: 10.1016/j.jocn.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/12/2024] [Accepted: 03/18/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Endovascular treatment of intracranial aneurysms (EVTIAs) is increasingly popular due to its minimally invasive nature and high success rate. While general anesthesia (GA) has been the historical preference for EVTIAs, there's growing interest in local anesthesia (LA). However, concerns persist about LA safety for EVTIAs. Therefore, we conducted a systematic review and meta-analysis to assess LA safety for EVTIAs. METHODS Following PRISMA guidelines, we searched PubMed, Embase, and Web of Science databases. Pooled analysis with 95 % confidence intervals (CI) assessed effects, I2 statistics gauged heterogeneity, and a random-effects model was adopted. Conversion to GA, neurological or procedure-related complications, intraoperative intracranial hemorrhagic complications (IIHC), and mortality were assessed. Subanalyses for ruptured and unruptured cases were performed. RESULTS The analysis included eleven studies, 2,133 patients, and 2,369 EVTIAs under LA. Conversion to GA rate was 1 % (95 %CI: 0 to 2 %). Neurological or procedure-related complications rate was 13 % (95 % CI: 8 % to 17 %). IIHC analysis revealed a rate of 1 % (95 % CI: 1 % to 2 %). The mortality rate was 0 % (95 %CI: 0 % to 0 %). Subanalyses revealed similar rates in ruptured and unruptured subgroups, except for a slightly high rate of complications and IIHC in the ruptured subgroup. CONCLUSION Findings indicate that EVTIA under LA is safe, with low conversion and mortality rates, even for ruptured aneurysms. Complications rates, also in IIHC rates, are comparable to those reported for GA, emphasizing LA's comparable safety profile in EVTIAs. Considering these promising outcomes, the decision to opt for the LA approach emerges as meaningful and well-suited for the endovascular treatment of aneurysms. Beyond its safety, LA introduces inherent supplementary advantages, including shortened hospitalization periods, cost-effectiveness, and an expedited patient recovery process.
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Affiliation(s)
- Sávio Batista
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, Brazil
| | | | | | | | - Eric Slawka
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
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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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Zottola ZR, Lehane DJ, Geiger JT, Kruger JL, Kong DS, Newhall KA, Doyle AJ, Mix DS, Stoner MC. Locoregional Anesthesia's Association With Reduced Intensive Care Unit Stay After Elective Endovascular Aneurysm Repair: Impact of Temporal Changes in Practice Patterns. J Surg Res 2024; 295:827-836. [PMID: 38168643 DOI: 10.1016/j.jss.2023.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 10/05/2023] [Accepted: 11/12/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Elective endovascular aneurysm repair (EVAR) can be performed via local anesthetics and/or regional (epidural or spinal) anesthesia (locoregional [LR]), versus general anesthesia (GA), conferring reduced intensive care unit (ICU) and hospital stays. Current analyses fail to account for temporal changes in vascular practice. Therefore, this study aimed to confirm reductions in ICU and hospital stays among LR patients while accounting for changes in practice patterns. MATERIALS AND METHODS Using the Society for Vascular Surgery's Vascular Quality Initiative, elective EVARs from August 2003 to June 2021 were grouped into LR or GA. Outcomes included ICU admission and prolonged hospital stay (>2 d). Procedures were stratified into groups of 2 y periods, and outcomes were analyzed within each time period. Univariable and multivariate analyses were used to assess outcomes. RESULTS LR was associated with reduced ICU admissions (22.3% versus 32.1%, P < 0.001) and prolonged hospital stays (14.3% versus 7.9%, P < 0.001) overall. When stratified by year, LR maintained its association with reduced ICU admissions in 2014-2015 (21.8% versus 34.0%, P < 0.001), 2016-2017 (23.6% versus 31.6%, P < 0.001), 2018-2019 (18.5% versus 30.2%, P < 0.001), and 2020-2021 (15.8% versus 28.8%, P < 0.001), although this was highly facility dependent. LR was associated with fewer prolonged hospital stays in 2014-2015 (15.6% versus 20.4%, P = 0.001) and 2016-2017 (13.3% versus 16.6%, P = 0.006) but not after 2017. CONCLUSIONS GA and LR have similar rates of prolonged hospital stays after 2017, while LR anesthesia was associated with reduced rates of ICU admissions, although this is facility-dependent, providing a potential avenue for resource preservation in patients suitable for LR.
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Affiliation(s)
- Zachary R Zottola
- University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Daniel J Lehane
- University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Josh T Geiger
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Joel L Kruger
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel S Kong
- Division of Vascular Surgery, Department of Surgery, MedStar Georgetown Hospital Center, Washington, District of Columbia
| | - Karina A Newhall
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Adam J Doyle
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Doran S Mix
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Michael C Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York.
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Jaffar-Karballai M, Al-Tawil M, Roy S, Kayali F, Vankad M, Shazly A, Zeinah M, Harky A. Local versus General Anaesthesia for Transcatheter Aortic Valve Implantation (TAVI): A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomised and Propensity-Score Matched Studies. Curr Probl Cardiol 2024; 49:102360. [PMID: 38128636 DOI: 10.1016/j.cpcardiol.2023.102360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) is a common practice for severe aortic stenosis, but the choice between general (GA) and local anesthesia (LA) remains uncertain. We conducted a comprehensive literature review until April 2023, comparing the safety and efficacy of LA versus GA in TAVI procedures. Our findings indicate significant advantages of LA, including lower 30-day mortality rates (RR: 0.69; 95% CI [0.58, 0.82]; p < 0.001), shorter in-hospital stays (mean difference: -0.91 days; 95% CI [-1.63, -0.20]; p = 0.01), reduced bleeding/transfusion incidents (RR: 0.64; 95% CI [0.48, 0.85]; p < 0.01), and fewer respiratory complications (RR: 0.56; 95% CI [0.42, 0.76], p<0.01). Other operative outcomes were comparable. Our findings reinforce prior evidence, presenting a compelling case for LA's safety and efficacy. While patient preferences and clinical nuances must be considered, our study propels the discourse towards a more informed anaesthesia approach for TAVI procedures.
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Affiliation(s)
| | | | - Sakshi Roy
- School of Medicine, Queen's University Belfast, Northern Ireland, UK
| | | | | | - Ahmed Shazly
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
| | - Mohamed Zeinah
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.
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6
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Villa F, Mozzetta G, Esposito D, Stefano LD, Pratesi G, Pulli R, Angiletta D, Piffaretti G. Results of the Italian Collaborators for Evar Registry on Acute Kidney Injury After Elective Endovascular Aortic Repair of Infrarenal Abdominal Aortic Aneurysm. J Endovasc Ther 2024:15266028241234277. [PMID: 38409775 DOI: 10.1177/15266028241234277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
OBJECTIVES To analyze the incidence and predictive factors of postoperative acute kidney injury (AKI) after elective standard endovascular aortic repair (EVAR) in a large recent, multicenter cohort. MATERIALS AND METHODS This is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study. Between January 2018 and March 2021, only patients treated with elective standard EVAR for infrarenal non-infected abdominal aortic aneurysm were analyzed. Patients already on hemodialysis (HD) were excluded. AKI was defined as an increase in serum creatinine (sCr) ≥0.3 mg/dL within 48 hours or an increase in sCr to ≥1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume of <0.5 mL/kg/h for 6 hours. Primary outcomes of interest were AKI incidence at 30 days and freedom from HD at 1-year follow-up. Secondary outcomes were freedom from severe postoperative complication, and freedom from aorta-related mortality (ARM) at 1 year. RESULTS The final cohort analyzed 526 (29.8%). There were 489 (93%) males and 37 (7%) females: the median age was 76 years (interquartile range [IQR], 71-81). Chronic kidney disease (CKD) was present in 86 (16.3%) patients. Early mortality was observed in 8 (1.5%) patients, none was aorta-related. Complication rate was 17.1% (n=89). AKI was observed in 17 (3.2%). Renal replacement therapy was needed in 4 (0.8%). HD was transitory in 2 cases and definitive in 1. Binary logistic regression analysis identified CKD (odds ratio [OR]: 4.68, 95% confidence interval [CI]: 2.10-10.45, p<0.001), and the presence of renal artery stenosis (OR: 3.80, 95% CI: 1.35-10.66, p=0.011) to be associated with an increased risk of postoperative AKI. Estimated freedom from ARM was 94.9% at 1 year. Estimated freedom from HD rate at 1 year was 94%: This was significantly different between patients with preoperative CKD and those who did not have preoperative CKD (log-rank, p=0.042). CONCLUSION AKI after elective standard EVAR still occurs but with an acceptably low incidence rate. Preoperative CKD is the most important predictor for postoperative AKI, which was not associated with the need for HD at 1-year follow-up but with a higher propensity of mortality. CLINICAL IMPACT This "real world" experience confirm that EVAR performed with standard contrats agent protocol remains safe for acute kidney injury development. Therefore, only patients presenting with preoperative borderline or ascertained chronic kidney disease will take the most advantage from the use of carbon dioxide contrast.
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Affiliation(s)
- Federico Villa
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Gaddiel Mozzetta
- Vascular Surgery, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa School of Medicine, Genoa, Italy
| | - Davide Esposito
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Florence School of Medicine, Florence, Italy
| | - Lucia Di Stefano
- Vascular Surgery, Department of Emergency and Organ Transplantation, University of Bari School of Medicine, Bari, Italy
| | - Giovanni Pratesi
- Vascular Surgery, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa School of Medicine, Genoa, Italy
| | - Raffaele Pulli
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Florence School of Medicine, Florence, Italy
| | - Domenico Angiletta
- Vascular Surgery, Department of Emergency and Organ Transplantation, University of Bari School of Medicine, Bari, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
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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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Zottola ZR, Kruger JL, Kong DS, Newhall KA, Doyle AJ, Mix DS, Stoner MC. Locoregional anesthesia is associated with reduced hospital stay and need for intensive care unit care of elective endovascular aneurysm repair patients in the Vascular Quality Initiative. J Vasc Surg 2023; 77:1061-1069. [PMID: 36400363 DOI: 10.1016/j.jvs.2022.11.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE It has been shown local or regional anesthetic techniques are a feasible alternative to general anesthesia for endovascular aortic aneurysm repair (EVAR). However, studies to date have shown controversial findings with respect to the benefit of locoregional anesthesia (LR) in the elective setting. The objective of this study is to compare postoperative outcomes between LR and general anesthesia (GA) in the setting of elective EVAR, using a large, multicenter database. METHODS Using the Society for Vascular Surgery Vascular Quality Initiative database, we retrospectively analyzed all patients who underwent elective EVAR from August 2003 to June 2021. Patients were grouped by anesthetic type based on the level of consciousness afforded by the anesthetic: local or regional anesthesia (LR) vs GA. Primary outcomes were total postoperative hospital length-of-stay (LOS) and intensive care unit (ICU) LOS. Propensity score matching was used for risk adjustment and to analyze the primary outcomes with confirmatory analysis using logistic or linear regression, as appropriate, in single and multilevel models. Secondary outcomes were 30-day mortality, 1-year mortality, postoperative outcomes, operative time, fluoroscopy time, and reoperation rate. These were analyzed following propensity score matching as well as using logistic regression and Cox proportional hazard regression in single and multilevel models, as appropriate. RESULTS A total of 50,809 patients underwent elective EVAR from 2003 to 2021. Of these, 4302 repairs used LR (8.5%) and 46,507 (91.5%) were performed under GA. After employing propensity score matching, two groups of 3027 patients were produced. These showed no significant difference in 30-day mortality (odds ratio, 1.22; P = .53), 1-year mortality (hazard ratio, 1.06; P = .62), or any postoperative outcomes. LR was found to be significantly associated with shorter hospital stays (≤2 days) (12.5% vs 14.8%; P = .01), decreased ICU utilization (19.3% vs 30.6%; P < .001), decreased operative time (110.8 vs 117.3 minutes; P < .001), decreased fluoroscopy time (21.0 vs 22.7 minutes; P < .001), and a slight reduction in reoperation rate (1.2% vs 1.9%; P = .02), which all remained significant following single-level and multilevel multivariate analyses accounting for hospital and physician random effects. CONCLUSIONS These data suggest that LR anesthesia is safe and may offer advantages in reducing resource utilization for patients undergoing elective EVAR, primarily based on associations with reduced ICU care and reduced hospital stay. Given these findings, LR may prove an advantageous technique in appropriately selected patient populations.
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Affiliation(s)
- Zachary R Zottola
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Joel L Kruger
- University of Rochester Medical Center, Division of Vascular Surgery, Department of Surgery, Rochester, NY
| | - Daniel S Kong
- Georgetown/Washington Hospital Center, Division of Vascular Surgery, Department of Surgery, Washington, DC
| | - Karina A Newhall
- University of Rochester Medical Center, Division of Vascular Surgery, Department of Surgery, Rochester, NY
| | - Adam J Doyle
- University of Rochester Medical Center, Division of Vascular Surgery, Department of Surgery, Rochester, NY
| | - Doran S Mix
- University of Rochester Medical Center, Division of Vascular Surgery, Department of Surgery, Rochester, NY
| | - Michael C Stoner
- University of Rochester Medical Center, Division of Vascular Surgery, Department of Surgery, Rochester, NY.
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9
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Ebeling C, Cheruku S. Anesthetic Management for Endovascular Repair of Thoracic and Abdominal Aortic Aneurysms. Anesthesiol Clin 2022; 40:719-735. [PMID: 36328625 DOI: 10.1016/j.anclin.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Aortic aneurysms-both abdominal and thoracic-are a significant cause of death and disability in the United States. Endovascular aneurysm repair has since become the preferred operative treatment of most thoracic and abdominal aneurysms because of a lower rate of complications and better outcomes compared with the open approach. Patients who present for endovascular aneurysm repair often have comorbid conditions related to their aortic pathology. These conditions should be evaluated and optimized before the procedure.
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Affiliation(s)
- Callie Ebeling
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Mail Code 9068, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Sreekanth Cheruku
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Mail Code 9068, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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10
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Pratesi C, Esposito D, Apostolou D, Attisani L, Bellosta R, Benedetto F, Blangetti I, Bonardelli S, Casini A, Fargion AT, Favaretto E, Freyrie A, Frola E, Miele V, Niola R, Novali C, Panzera C, Pegorer M, Perini P, Piffaretti G, Pini R, Robaldo A, Sartori M, Stigliano A, Taurino M, Veroux P, Verzini F, Zaninelli E, Orso M. Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE). THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:328-352. [PMID: 35658387 DOI: 10.23736/s0021-9509.22.12330-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.
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Affiliation(s)
- Carlo Pratesi
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Davide Esposito
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy -
| | | | - Luca Attisani
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Raffaello Bellosta
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Filippo Benedetto
- Department of Vascular Surgery, AOU Policlinico Martino, Messina, Italy
| | | | | | - Andrea Casini
- Department of Intensive Care, Careggi University Hospital, Florence, Italy
| | - Aaron T Fargion
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Elisabetta Favaretto
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Freyrie
- Department of Vascular Surgery, Parma University Hospital, Parma, Italy
| | - Edoardo Frola
- Department of Vascular Surgery, AO S. Croce e Carle, Cuneo, Italy
| | - Vittorio Miele
- Department of Diagnostic Imaging, Careggi University Hospital, Florence, Italy
| | - Raffaella Niola
- Department of Vascular and Interventional Radiology, AORN Cardarelli, Naples, Italy
| | - Claudio Novali
- Department of Vascular Surgery, GVM Maria Pia Hospital, Turin, Italy
| | - Chiara Panzera
- Department of Vascular Surgery, AOU Sant'Andrea, Rome, Italy
| | - Matteo Pegorer
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Paolo Perini
- Department of Vascular Surgery, Parma University Hospital, Parma, Italy
| | | | - Rodolfo Pini
- Department of Vascular Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Alessandro Robaldo
- Department of Vascular Surgery, Ticino Vascular Center - Lugano Regional Hospital, Lugano, Switzerland
| | - Michelangelo Sartori
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | | | | | - Fabio Verzini
- Department of Vascular Surgery, AOU Città della Salute e della Scienza, Turin, Italy
| | - Erica Zaninelli
- Department of General Medical Practice, ATS Bergamo - ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Massimiliano Orso
- Istituto Zooprofilattico Sperimentale dell'Umbria e delle Marche, Perugia, Italy
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Abisi S, Musto L, Lyons O, Carmichael M, Sallam M, Gkoutzios P, Zayed H, Puchakayala M. "Awake" Spinal Cord Monitoring Under Local Anesthesia and Conscious Sedation in Fenestrated and Branched Endovascular Aortic Repair. J Endovasc Ther 2021; 28:837-843. [PMID: 34180738 DOI: 10.1177/15266028211028207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Endovascular repair of thoracoabdominal aortic aneurysms carries a risk of spinal cord ischemia, the causes of which remain uncertain. We hypothesized that local anesthesia (LA) with conscious sedation could abrogate the potential suppressive cardiovascular effects of general anesthesia (GA) and facilitate intraoperative monitoring of neurological function. Here, we examine the feasibility of this technique during fenestrated (FEVAR) or branched endovascular aortic repair (BEVAR). MATERIALS AND METHODS Consecutive patients undergoing FEVAR or BEVAR under LA and conscious sedation by a team at a single center were analyzed. Patients received conscious sedation using intravenous remifentanil and propofol infusions in conjunction with a local anesthetic agent. No patient had a prophylactic spinal drain inserted. Outcome measures included conversion to GA, need for vasopressors and/or spinal drainage, length of stay, complications, and patient survival. RESULTS A total of 44 patients underwent FEVAR or BEVAR under LA and conscious sedation. The cohort included thoracoabdominal aortic aneurysms (n=41) and pararenal aneurysms treated with endografts covering the supraceliac segment (n=3). Four patients (9%) required conversion to GA at a median operative duration of 198 minutes (range 97-495 minutes). Vasopressors were required intraoperatively in 3 of the cases that were converted to GA. No patient developed spinal cord ischemia and none had insertion of a spinal drain. The median hospital length of stay was 4 days (range 2-41 days). Postoperative delirium and hospital-acquired pneumonia was seen in 7% of patients. All patients survived to 30 days, with 95% alive at a median follow-up of 15 months (range 3-26 months). CONCLUSION LA and conscious sedation is a feasible anesthetic technique for the endovascular repair of thoracoabdominal aortic aneurysms.
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Affiliation(s)
- Said Abisi
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Liam Musto
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Oliver Lyons
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Michelle Carmichael
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Morad Sallam
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Panos Gkoutzios
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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12
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Anesthetic Considerations for Endovascular Neurologic, Vascular, and Cardiac Procedures. Adv Anesth 2020; 38:63-95. [PMID: 34106841 DOI: 10.1016/j.aan.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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Nikol S, Mathias K, Olinic DM, Blinc A, Espinola-Klein C. Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review. VASA 2020; 49:1-36. [PMID: 32856993 DOI: 10.1024/0301-1526/a000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.
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Affiliation(s)
- Sigrid Nikol
- Department of Angiology, ASKLEPIOS Klinik St. Georg, Hamburg, Germany.,University of Münster, Germany
| | - Klaus Mathias
- World Federation for Interventional Stroke Treatment (WIST), Hamburg, Germany
| | - Dan Mircea Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy and Interventional Cardiology Department, Emergency Hospital, Cluj-Napoca, Romania
| | - Aleš Blinc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
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Melnyk V, Fedorko L, Djaiani G. Xenon Anesthesia: Is it in Due Course for a Mainstream Comeback? J Cardiothorac Vasc Anesth 2019; 34:134-135. [PMID: 31587929 DOI: 10.1053/j.jvca.2019.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/08/2019] [Indexed: 11/11/2022]
Affiliation(s)
- V Melnyk
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - L Fedorko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - G Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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