Learning objectives
- Etiology and complications of abdominal aortic aneurysm (AAA)
- Anesthetic management of Abdominal aortic aneurysm (AAR) repair through an open incision or through EndoVascular Aneurysma Repair (EVAR)
Definition and mechanisms
- Abdominal aortic aneurysm (AAR) repair is a procedure used to treat an aneurysm of the abdominal aorta
- An aneurysm is a bulging, weak spot in the aorta that may be at risk for rupturing
- small AAA: 3-4.4 cm across
- medium AAA: 4.5-5.4 cm across
- large AAA: ≥5.5 cm more across
- The incidence of AAA increases with age
- Repair of an abdominal aortic aneurysm may be performed surgically through an open incision or in a minimally-invasive procedure called endovascular aneurysm repair (EVAR)
- In the EVAR procedure, a stent graft is inserted into the aneurysm through small incisions in the groin
Etiology
| Atherosclerosis | |
| Cystic medial necrosis | |
| Connective tissue disorders | Marfan’s syndrome Ehlers Danlos syndrome type IV Turner's syndrome Polycystic kidney disease |
| Arterirtis | Giant cell arteritis Takayasu's disease Relapsing polychondritis |
| Infections | Acute: syphilis, salmonella, staphylococcus, brucellosis Chronic: tuberculosis, fungal (mycotic) |
| Posttraumatic | |
| Inflammatory |
Risk factors
- Age > 60 years
- Male
- Family history
- Hyperlipidemia
- Hypertension
- Chronic obstructive pulmonary disease
- Smoking
- Diabetes
- Caucasian race
- Sedentary life style
- Coronary artery disease
- Peripheral vascular disease
Management
Preoperative management
Similar for open repair and EVAR
- Start patients on statins and antiplatelet medications
- Control arterial pressure
- Perform standard investigations: full blood count, electrolytes, ECG, chest X-ray, urinalysis
- Assess major cardiac risk factors:
- Decompensated heart failure
- Acute coronary syndrome
- Arrhythmias
- Valvular disease
- Worsening ischemic heart disease
- Recent MI
- Consider:
- Diuretics and ACE inhibitors
- Potential for hemorrhage, large fluid shifts & hypothermia
Perioperative management: open incision
Perioperative management: EVAR
Perioperative management: ruptured AAA
Postoperative management: open repair and EVAR
Postoperative complications open repair
| Respiratory complications | Pneumonia Atelectasis Respiratory failure Pulmonary thromboembolism |
| Cardiovascular complications | Myocardial ischemia Myocardial infarction Dysrhythmias |
| Cerebrovascular complications | Cerebrovascular disease Carotid insufficiency Postoperative cognitive dysfunction Confusion/delirium |
| Renal complications | AKI CKD Dialysis acute tubular necrosis Renal vascular injury Ureteral injury |
| Gastrointestinal complications | Bowel ischemia ACS paralytic ileus |
| Neurological complications | Spinal cord ischemia Paraplegia |
| Surgical complications | Bleeding Wound dehiscence Incisional hernia Venous thromboembolism Wound infection Leg ischemia Graft infection Graft thrombosis |
Postoperative complications EVAR
| Surgical | Medical |
|---|---|
| Maldeployment of malposition of graft Arterial rupture/arterial dissection Delayed AAA rupture Stent-graft limb thrombosis leading to lower limb ischemia Graft migration Endoleak Rupture of iliac artery Ischemia of spinal cord, kidneys, liver, bowel, legs Graft infection Paralysis | Acute coronary syndromes Acute congestive cardiac failure Acute kidney injury (AKI)/CIN arrhythmia Respiratory infection Venous thromboembolism Cerebovascular accident Postimplantation syndrome |
Suggested reading
- Kothandan H, Haw Chieh GL, Khan SA, Karthekeyan RB, Sharad SS. Anesthetic considerations for endovascular abdominal aortic aneurysm repair. Ann Card Anaesth. 2016;19(1):132-141.
- Al-Hashimi M, Thompson J. Anaesthesia for elective open abdominal aortic aneurysm repair, Continuing Education in Anaesthesia Critical Care & Pain, Volume 13, Issue 6, December 2013, Pages 208–212.
- Gelzinis TA, Subramaniam K. Anesthesia for Open Abdominal Aortic Aneurysm Repair. Anesthesia and Perioperative Care for Aortic Surgery. 2010;301-327.
- Nataraj V, Mortimer AJ. Endovascular abdominal aortic aneurysm repair, Continuing Education in Anaesthesia Critical Care & Pain, Volume 4, Issue 3, June 2004, Pages 91–94.
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