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Chauhan R, Balakrishnan I, Mishra K, Kumar V. Ruptured Aortic Aneurysm in Pregnancy, Anesthetic Management of Endovascular Procedure. Ann Card Anaesth 2024; 27:249-252. [PMID: 38963361 PMCID: PMC11315253 DOI: 10.4103/aca.aca_111_23] [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: 07/13/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 07/05/2024] Open
Abstract
ABSTRACT Advanced pregnancy is associated with a higher risk of complicated aortopathies owing to the physiologic changes in pregnancy. The diagnosis can be elusive due to its rare incidence. The optimal treatment strategy is chosen based on the clinical condition of the patient, gestational age, and the severity of the aortic disease. A healthy young primigravida presented with acute chest pain in the early second trimester, diagnosed as a thoracic aortic aneurysm that had ruptured causing hemothorax. She underwent emergency endovascular repair under general anesthesia. Aortic disease should always be ruled out early in acute chest pain in pregnancy. Expeditious and strategic management helps improve maternal and fetal outcomes.
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Affiliation(s)
- Richa Chauhan
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ira Balakrishnan
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Keshabanand Mishra
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Virendra Kumar
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Boucher N, Dreksler H, Hooper J, Nagpal S, MirGhassemi A, Miller E. Anaesthesia for vascular emergencies - a state of the art review. Anaesthesia 2023; 78:236-246. [PMID: 36308289 DOI: 10.1111/anae.15899] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 01/11/2023]
Abstract
In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.
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Affiliation(s)
- N Boucher
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - H Dreksler
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - J Hooper
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,Department of Critical Care, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - S Nagpal
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - A MirGhassemi
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - E Miller
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
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Li G, Xu X, Li J, Xiong S. Thoracic Endovascular Aortic Repair for Retrograde Type A Aortic Intramural Hematoma. Front Cardiovasc Med 2021; 8:712524. [PMID: 34527712 PMCID: PMC8435682 DOI: 10.3389/fcvm.2021.712524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/29/2021] [Indexed: 01/16/2023] Open
Abstract
Objectives: To evaluate the effects of thoracic endovascular aortic repair (TEVAR) in descending aorta for retrograde type A aortic intramural hematoma (re-TAIMH). Methods: From January 2013 to September 2019, 65 consecutive patients diagnosed with re-TAIMH and treated by TEVAR were enrolled in this retrospective cohort study, of whom 44 patients presented with entry tear in descending aorta (Group A) and 21 with penetrating atherosclerotic ulcer (Group B). The clinical data, including baseline characteristics, adverse events, aortic remolding, and overall survival were reviewed. Results: The mean age of all the patients was 52.0 ± 8.3 years, and 54 (83.1%) patients were men. The mean maximal ascending aortic diameter (MAAD) was 43.1 ± 5.4 mm, and the mean maximal ascending aortic hematoma thickness (MAAHT) was 9.6 ± 4.7 mm. TEVAR was performed under general anesthesia in 53 (81.5%) patients, while 12 (18.5%) patients were treated under local anesthesia. There were two deaths during hospitalization (one with rupture and another with multiple organ dysfunction syndrome), and overall survival at 1, 4, and 7 years for all 65 patients was 93.8, 92.0, and 87.4%, respectively. The MAAD and MAATH decreased significantly after TEVAR (p < 0.05) in the two groups, so did the mean descending aortic diameter at the pulmonary bifurcation level. Type I endoleak, dialysis, progression to type A aortic dissection, and enlargement in MAAHT and MAAD were more common complications, which occurred in four, three, two, and two patients, respectively. Conclusion: Patients with retrograde TAIMH treated by TEVAR had a favorable prognosis including late survival and aortic remolding. However, some post-intervention complications were not negligible.
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Affiliation(s)
- Gen Li
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Xu
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Li
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China
| | - Sizheng Xiong
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China
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Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, Murad MH, Perry RJ, Singh MJ, Veeraswamy RK, Wang GJ. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg 2021; 73:55S-83S. [DOI: 10.1016/j.jvs.2020.05.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
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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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Wang KR, Gao M, Wen XH, Kong HY. Anaesthetic management in endovascular total aortic arch repair via needle-based in situ fenestration: a case series of 14 patients. J Int Med Res 2019; 48:300060519893517. [PMID: 31878814 PMCID: PMC7645359 DOI: 10.1177/0300060519893517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective Endovascular total aortic arch repair (ETAAR) via needle-based in situ fenestration (ISF) is a major challenge for anaesthesiologists because of haemodynamic instability and the risk of cerebral hypoxia. We herein summarise our experience with anaesthetic management of patients who underwent this procedure. Methods Fourteen patients who underwent ETAAR via ISF for arch pathologies involving the major supra-arch branches were included. Regional cerebral oxygen saturation was measured to monitor cerebral perfusion. Partial extracorporeal circulation (EC) support from the right common femoral vein to the right axillary artery was introduced to provide cerebral perfusion. Results During ISF, vessel rupture occurred in three patients and ventricular fibrillation occurred in one patient. The regional cerebral oxygen saturation significantly decreased during the potential risk period for cerebral ischaemia. Establishment of EC effectively prevented cerebral ischaemia. Conclusions During ETAAR, the risks of haemodynamic instability caused by the procedure and vessel rupture during ISF need to be overcome. Partial EC ensured good cerebral protection in our study, and regional cerebral oxygen saturation monitoring may help to reduce the rate of desaturation.
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Affiliation(s)
- Kui-Rong Wang
- Department of Anaesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P.R. China
| | - Min Gao
- Department of Anaesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P.R. China
| | - Xiao-Hong Wen
- Department of Anaesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P.R. China
| | - Hai-Ying Kong
- Department of Anaesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P.R. China
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Bennett KM, McAninch CM, Scarborough JE. Locoregional anesthesia is associated with lower 30-day mortality than general anesthesia in patients undergoing endovascular repair of ruptured abdominal aortic aneurysm. J Vasc Surg 2019; 70:1862-1867.e1. [DOI: 10.1016/j.jvs.2019.01.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/11/2019] [Indexed: 12/19/2022]
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Thomas RP, Amin SS, Eldergash O, Kowald T, Bremer S, Easo J, Weymann A, Book M, Szczechowicz M, Schmuck B, Chavan A. Urgent Endovascular Treatment for Non-traumatic Descending Thoracic Aortic Rupture. Cardiovasc Intervent Radiol 2018; 41:1318-1323. [PMID: 29948006 DOI: 10.1007/s00270-018-2006-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 06/04/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the efficacy of endovascular repair of non-traumatic rupture of the descending thoracic aorta. MATERIALS AND METHODS From January 2011 to August 2017, 22 consecutive patients (16 men, mean age 73.7 years, range 63-92 years) with non-traumatic rupture of the descending thoracic aorta were treated endovascularly. Thirty-day mortality as well as procedure-related morbidity including stroke, renal, pulmonary and spinal complications were retrospectively assessed. Median follow-up was 29 months (range 6-65 months). RESULTS Nine patients had type B dissections, and 13 had atherosclerotic aortic aneurysms. The technical success was 100%; 86.3% of patients (19/22) were treated percutaneously. Thirteen patients (59%) received a single endograft, 8 (36%) received 2 endografts, and 1 received 3 endografts. The endograft diameters ranged between 28 and 46 mm. Two dissection patients received additional distal bare metal true lumen stents. Eleven patients required additional drainage of thoracic hematoma. Three primary percutaneous sites (15.7%) required surgical revision. No spinal cord ischemic or renal complications were observed. Stroke was observed in 2 patients (9%), both with full coverage of left subclavian artery origin. Four patients (18%) required tracheostomy with prolonged respiratory support (range 10-15 days). The median intensive care unit stay was 5 days (range 1-27 days). The 30-day mortality was 18.1% (4/22). CONCLUSION Endoluminal repair of non-traumatic rupture of the descending thoracic aorta can be performed percutaneously. It showed a 30-day mortality of 18.1%, and no spinal cord injury or renal complications were observed in surviving patients at follow-up. LEVEL OF EVIDENCE Level 4, case series.
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Affiliation(s)
- Rohit Philip Thomas
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany.
| | - Sandeep Sunder Amin
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Osama Eldergash
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Tobias Kowald
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Sebastian Bremer
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Jerry Easo
- Department of Cardiac Surgery, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Malte Book
- Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Marcin Szczechowicz
- Department of Cardiac Surgery, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Bernhard Schmuck
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
| | - Ajay Chavan
- Institute of Diagnostic and Interventional Radiology, Klinikum Oldenburg AöR, Rahel Straus Strasse 10, 26133, Oldenburg, Germany
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Tanaka A, Estrera AL. Awake TEVAR for Ruptured Thoracic Aneurysms: Less Is More? Semin Thorac Cardiovasc Surg 2018; 30:40-41. [PMID: 29452263 DOI: 10.1053/j.semtcvs.2018.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth) and Memorial Hermann Hospital, Houston, Texas
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth) and Memorial Hermann Hospital, Houston, Texas.
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Kim DS, Na HS, Lee JH, Shin YD, Shim JK, Shin HW, Kang H, Joung KW. Current clinical application of dexmedetomidine for sedation and anesthesia. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.4.306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Doo Sik Kim
- Department of Anesthesiology and Pain Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Hyo-seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Ji-hyang Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Young Duck Shin
- Department of Anesthesiology and Pain Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Won Shin
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hyoseok Kang
- Department of Anesthesiology and Pain Medicine, Eulji Hospital, Eulji University College of Medicine, Seoul, Korea
| | - Kyoung-Woon Joung
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Gabriel SA, Rinaldi E, Leopardi M, Melissano G, Chiesa R. TEVAR for ruptured descending thoracic aortic aneurysm: case report. J Vasc Bras 2016; 15:322-327. [PMID: 29930612 PMCID: PMC5829733 DOI: 10.1590/1677-5449.006716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A ruptured descending thoracic aortic aneurysm (rDTAA) is a life-threatening condition associated with high morbidity and mortality. Endovascular treatment for rDTAA promotes effective aneurysm exclusion with a minimally invasive approach. The authors report a case of a 76-year-old man with hemodynamically unstable 9-cm-diameter rDTAA treated with emergency thoracic endovascular aortic repair (TEVAR).
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Affiliation(s)
- Sthefano Atique Gabriel
- Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Fellow of Advanced Aortic Surgery, Milan, Italy
| | - Enrico Rinaldi
- Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Vascular Surgery, Milan, Italy
| | - Marco Leopardi
- Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Vascular Surgery, Milan, Italy
| | - Germano Melissano
- Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Vascular Surgery, Milan, Italy
| | - Roberto Chiesa
- Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Vascular Surgery, Milan, Italy
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Gerstein NS, Panikkath PV, Carlson AP, Pollock DM, Tayler E, Augoustides JG. CASE 4—2016. J Cardiothorac Vasc Anesth 2016; 30:548-54. [DOI: 10.1053/j.jvca.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Indexed: 01/16/2023]
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Abstract
Patients undergoing vascular surgery present a myriad of perioperative challenges due to the complex comorbidities affecting them in conjunction with high-risk surgical procedures. Additionally, advances in endovascular technology have enabled surgical procedures to be performed on patients who would not have been considered surgical candidates in the past. This combination of increasing patient morbidity and evolving surgical technique requires a well-planned preoperative assessment and close communication with surgical and perioperative colleagues. This article outlines an appropriate approach by first considering each organ system, followed by review of considerations unique to various surgical procedures, and then an overall assessment of risk.
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Tagarakis GL, Whitlock RP, Gutsche JT, Diegeler A, Patel PA, Daskalopoulos ME, Vernick WJ, Anastasiadis K, Augoustides JG. New frontiers in aortic therapy: focus on deliberate hypotension during thoracic aortic endovascular interventions. J Cardiothorac Vasc Anesth 2014; 28:843-7. [PMID: 24746338 DOI: 10.1053/j.jvca.2014.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Georgios L Tagarakis
- Department of Surgery, AHEPA Hospital, Aristotle University, Thessaloniki, Greece
| | | | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - William J Vernick
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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