Type of Anesthesia for Endovascular Abdominal Aortic Aneurysm Repair

Abstract

Objective: Endovascular aneurysm repair (EVAR) is increasingly used in the management of patients with abdominal aortic aneurysms (AAA), including in the emergency setting for ruptured AAA. The lower mortality amongst patients undergoing emergency EVAR under local anesthesia (LA) observed in the IMPROVE trial has sparked renewed interest in the anesthesia choice for EVAR. This systematic review evaluates the effect of mode of anesthesia on outcomes after EVAR. Design: The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was inhospital/30-day mortality and both emergency and elective EVAR were included. The relative risk of death was estimated for each individual study without adjustment for potential confounding factors. Setting: Hospitals. Participants: A total of 39,744 patients from 22 non-randomized studies were included in the analysis. Interventions: None Measurements and Main Results: Sixteen studies in 23,202 patients compared LA to GA and reported in-hospital/30-day mortality. The unadjusted risk of death after emergency EVAR with LA was lower than with GA. Trends in elective surgery were less clear. Conclusions: There is some evidence across both emergency and elective settings to suggest that mode of anesthesia may be associated with improved outcomes. In particular, 3 LA appears to have a positive effect on outcome after emergency EVAR. Due to the lack of randomized trial data, a significant risk of confounding remains. The optimal mode of anesthesia for EVAR should be further investigated and the reasons why particular anesthesia techniques are chosen for particular patients identified.

Does Less Invasive Surgery Need Less Invasive Anesthesia?

“…Dexmedetomidine has an excellent safety record in very frail patient populations undergoing high-risk cardiac surgery and a transcatheter aortic valve replacement. 12 In conclusion, we agree with Armstrong et al 6 that future randomized controlled trials pertinent to the mode of anesthesia for EVAR should not be limited to comparing 30-day mortality but rather focus on more patient-centered outcomes, such as long-term morbidity and mortality, the rate of re-intervention, incidence of prolonged cognitive decline, and postoperative quality of life. Future, multicenter randomized controlled trials are highly desirable and will need to confirm the benefits of local anesthesia in patients undergoing EVAR procedures.…”

“…Fourteen studies included only patients who underwent elective EVAR procedures, and 4 studies focused exclusively on emergency EVAR (approximately 3,200 patients). 6 The main finding of this meta-analysis was that unadjusted risk of death after emergency EVAR performed with local anesthesia was significantly lower compared with general anesthesia. The authors could not confirm the same trends in elective EVAR.…”

“…The findings by Armstrong et al 6 regarding the risk reduction associated with local anesthesia after emergency EVAR deserves recognition. Mortality after emergency EVAR for ruptured AAA still is very high, ranging from 25% to 31%, and has not decreased over the last decade.…”

“…In this issue of the journal, Armstrong et al 6 published a systematic review and meta-analysis evaluating the current evidence pertinent to the effects of type of anesthesia and postoperative outcome after EVAR procedures. The authors performed a comprehensive data analysis of high-quality observational studies.…”

Patients’ lived experiences of waiting for and undergoing endovascular aortic repair in a hybrid operating room: A qualitative study

“…Endovascular aortic repair, which is the preferable treatment for aortic aneurysms, can be performed with general, regional or local anaesthesia (Andres et al, ). The number of procedures performed with regional or local anaesthesia may increase in number since they are associated with more positive outcomes (Armstrong, Squire, Rogers, Hinchliffe, & Mouton, ). This trend means that more patients will probably be awake during this kind of procedure in the future; therefore, knowing their experiences of the hybrid OR environment becomes even more valuable.…”