endovascular AAA repair w/ fenestrated graft

[toughlife]

54 y/o, 147 kg, with 6.2 x 6.3cm infrarenal AAA scheduled for endovascular placement of fenestrated graft. Hx of CAD s/p PCI with stent >8 months ago, 75-pack yr hx of smoking, dobutamine stress test WNL, HTN and on nitro for "ocassional" CP.

what's your experience with doing these type of cases? Tips?

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[DuckhuntingDoc]

I have done them a couple different ways. A-line, good PIV, introducer, and MAC. A-line, 2 good PIV's, and tube. Pucker factor is still high but it's way better than an open case...Which it could turn into at any second.
The only tip I can give you is be prepared to open. Have your drips ready, blood in room, etc, etc.

 

[Gas]

Being 147 kg and a smoker, consider a spinal or epidural too. Just tell the surgeon to wait for intra-op heparinization. Or do a GA - this guy may be too big for a MAC, especially since these cases can be a few hours.

Last one I did was GA and turned into a bloodbath. Have central access, blood, and all drugs ready to go.

 

[Jeff05]

we have a surgeon that does these in about 3 hours with minimal EBL.
a-line a couple of 16 gauge/RICs and a spinal do the trick.

 

[Noyac]

Or you could do it with just a good PIV. A lot depends on the surgeon and your comfort level with that surgeon.

 

[Arch Guillotti]

Seems like we do them with 2 good peripheral IV's and an arterial line around here with geta. I think the conversion rate is pretty low if the surgeon is good. If I am not mistaken, bleeding problems usually occur while gaining access or at the ned of the procedure, though of course the threat of big red problems is always there. I think that some of our guys do a long acting CSE and pull the catheter in the PACU when the ACT is normal but I don't think that I have ever done one under regional anesthesia. Seems like our vascular guys want everybody to be asleep. I think that for your pt. a regional would be good given his lungs, but I really don't like sedating people that big. Seems like they are always very "squirelly". I would probably opt for a general. Wouldn't put in a central line unless access was really poor.

 

[militarymd]

I personally would do it under general with a ETT if I knew nothing about the surgeon.

Nothing worse than flailing with an airway when the s h i t hits the fan.

 

[BlackSails]

I saw an open AAA repair once. If I recall correctly, the anesthesiologist had an A-line, a central line, an IV and I think maybe another central line.

 

[treasurefull2]

From a med student's point of view. I think Safer is Better than Sorry. Why not secure a central line. If something goes wrong with AAA repair, it goes REALLY wrong. The benefits seems to outweigh the risk of a central access.

 

[Noyac]

Those of you that want to do regional, can you give me the course of events when the aneurysm ruptures?

 

[huktonfonix]

As far as fluid administration is concerned, theres not much a central line (aside from a cordis) is going to offer me that a couple of good (16+) peripheral IVs won't. I've done these with an aline and a couple of good IVs.

 

[urge]

Those of you that want to do regional, can you give me the course of events when the aneurysm ruptures?

"Sir, you are about to die. Do you have any last words?"

 

[BlackSails]

As far as fluid administration is concerned, theres not much a central line (aside from a cordis) is going to offer me that a couple of good (16+) peripheral IVs won't. I've done these with an aline and a couple of good IVs.

Im going to guess that 16+ is the size, and not the number of IVs you place.

 

[DuckhuntingDoc]

"Sir, you are about to die. Do you have any last words?"

it's funny cause it's true.

 

[joncmarkley]

Our surgeon has his cut down done and ready for the heparin about 35 minutes after spinal is in....are you guys waiting the obligatory ASRA 1 hour before heparin or sneaking it in early.

thanks

 

[Noyac]

Our surgeon has his cut down done and ready for the heparin about 35 minutes after spinal is in....are you guys waiting the obligatory ASRA 1 hour before heparin or sneaking it in early.

thanks

Not for a spinal but probably would for an epidural.

I personally think these are better done under GA though. If something goes wrong, you got a lot of work to do and to add having to put the guy to sleep on top of that is just more than I want to be doing. If the aorta goes these guys get very fidgety, start to puke, and become inconsolable. Pushing an induction agent at this time is also not very fun. You can do it but why?

I know the argument that under epidural you don't have to convert if they need to open. How many of you have done a AAA under epidural alone? Like I said, its doable but why?

 

[toughlife]

We went with GETA, one 14 and 16g IVs, a-line, and introducer. We also put a spinal drain per surgeons' request. Was impressed with the look of that 14g tuohy. cool case.

 

[Idiopathic]

Ive done probably five of these awake. Why do you need regional? 16g or 2 18g and one a-line. Am I missing something about the case that would cause you guys to go to sleep?

I guess worst case scenario is a tear and conversion to open, in which case you induce and throw in a cordis.

 

[deleted9493]

Yeah, for an endovascular repair, what exactly is the cost/benefit ratio of using a regional? I mean, it makes sense in the open repair setting but here?

Gas, you suggest a spinal or epidural because of his weight and status as a smoker...do you mind sharing your rationale on that?

 

[Gas]

Weight - possible difficult airway, COPD/Asthma - if advanced, maybe better to avoid an ETT. I do tend to do these cases under GA - if the aneurysm ruptures or bleeds, not good to have a regional on board contributing to hypotension. But if I trust the surgeon (probably most important factor) and they are relatively fast, it is possible to use other techniques if the risks/benefits of those other techniques are warranted. But like I said, GA is the way to go in most cases - most control. I've actually done a few of these under MAC too. Works, but each case has to be individualized.

 

[sevo85288]

What would you guys do if your IR doc dude asked you to start one of these cases in the cath lab at 500 PM. One of my partners recently did one of these late in the day, sick pt, in IR, with no back up and under-trained IR staff. Any thoughts about logistics of remote cases/control over time, etc....
thanks

 

[Gas]

What would you guys do if your IR doc dude asked you to start one of these cases in the cath lab at 500 PM. One of my partners recently did one of these late in the day, sick pt, in IR, with no back up and under-trained IR staff. Any thoughts about logistics of remote cases/control over time, etc....
thanks

I'd have to say no. Thankfully, our hospital administration will back us up on this, since it's happened to us. You need backup as well as nurses who are more used to this kind of thing. If I ask an IR nurse to get me blood/levophed, etc, guaranteed that I won't get them.

On top of that, you start the case at 5PM, case is done by 9 or 10 PM, then what? You just go home? I would rather be around for some time afterwards while the patient is in PACU/ICU.

 

[cchoukal]

From a med student's point of view. I think Safer is Better than Sorry. Why not secure a central line. If something goes wrong with AAA repair, it goes REALLY wrong. The benefits seems to outweigh the risk of a central access.

I think people generally overestimate the importance of central access. If you have a triple lumen catheter, your total flow rate (based on the rates actually printed on the package) buys you the equivalent of an 18g peripheral (that is, not so hot for resuscitation). Measuring central pressures is sometimes useful, but in the case of the AAA, you pretty much know what the deal is: hemorrhagic shock. If you insert an introducer, you obviously upgrade your flow rate considerably (an advantage which disappears if you fill that huge lumen with a pulmonary artery catheter). That said, a couple of 14s or an RIC can equal that flow rate without the complications of a central line, particularly if coagulopathy is part of the equation.

 

[2ndyear]

I agree. RIC caths are great little additions to your toolbox with essentially zero risk compared to a central line. We get to rotate for a month with a private practice group and I do notice a difference in practice regarding central lines. At our academic hospital, we probably put in more lines using the "well the patient will need it later on" clause. Sure, let the surgeons do it in the unit then is the private practice mantra. The exception being, of course, swan placement (overrated in many instances), and when you just can't secure anything else big enough for volume.

I was in on a case gone bad recently. Lap adrenalectomy, not a pheo. Surgeons hit the IVC. I went to the room with a few others. Patient lateral under the drapes, one 18 ga IV. I threw in a short 14, someone set up the level one and there you go. 2 L blood loss futzing around before they opened, but we were fine. I would have probably put in another IV from the start, before positioning, but I didn't start the case.

 

[Laryngospasm]

54 y/o, 147 kg, with 6.2 x 6.3cm infrarenal AAA scheduled for endovascular placement of fenestrated graft. Hx of CAD s/p PCI with stent >8 months ago, 75-pack yr hx of smoking, dobutamine stress test WNL, HTN and on nitro for "ocassional" CP.

what's your experience with doing these type of cases? Tips?

GETA with large bore peripheral IVs, and I agree with noyac, we have some very skilled surgeons and some hacks, depends on which you are working with and your level of comfort.

 

[Idiopathic]

pretty much all the endovascular ones we do are MAC cases, AFAIK. Iver not put someone to sleep for an EV graft and we typically avoid regional for these, although an elective open AAA is a different story obviously. i still dont see where your benefit comes from going to sleep, unless its our version of 'proximal control'

 

[drccw]

At the VA, the endovascular repairs go like this:
- down in IR; far away from the OR
- One (maybe two) large bore IVs
- NIBP, ECG, SPO2
- LEP

The conversion rate over the past 5 years apparently is 1 from what I have heard. The LEP is something for the residents to do-> doing this under local could perhaps be possible in the future. We dont place an a-line because there already is a large arterial line in place.

At the trauma center some of the emergent (IE leaking or ruptured ones) are being down awake from an endovascular approach. A-line, MAC, cordis if they can.

Elective bad ones at the university center are done with all the big guns: GETA, a-line, cordis (Big MAC) and all the drips.... But even there the conversion rate is low-> but there has been occasions when due to bleeding from the cannulae sites that they have had a significant blood transfusion requirement (they can accumulate a lot of blood at the cutdown sites without realization)

chris

 

[Laryngospasm]

pretty much all the endovascular ones we do are MAC cases, AFAIK. Iver not put someone to sleep for an EV graft and we typically avoid regional for these, although an elective open AAA is a different story obviously. i still dont see where your benefit comes from going to sleep, unless its our version of 'proximal control'

So you do a MAC on a 325lb patient, who probably has Pulm HTN, OSA and let his ETCO2 climb to what 70? Then when he obstructs how do you handle it? Surgeons are not fond of movement during an endovascular procedure.

 

[VentdependenT]

So you do a MAC on a 325lb patient, who probably has Pulm HTN, OSA and let his ETCO2 climb to what 70? Then when he obstructs how do you handle it? Surgeons are not fond of movement during an endovascular procedure.

I never base my entire anesthetic on the procedure itself. It also depends on:

1)pt's underlying conditions
2)patient body habitus
3)surgical positioning
4)surgeons desire/comfort

A 350 lb dude with pulm htn and OSA gets tubed and will get a slow ween in the unit. No bonus cookie gold stars for doing this guy under MAC. He's going to the unit no matter what. And if I'm doing the case, he's going with a tube and a precedex ggt (hemodynamics tolerating of course).

That being said, we usually do these cases with A-line, 2 big piv, MAC, and epidural. $hit happens and thats why everything else you need is there in the room ready to rock. Including the pads.

Why do we do it that way? Thats the way its been done here for a while. Nothing else I can say.

 

[coprolalia]

From a med student's point of view. I think Safer is Better than Sorry. Why not secure a central line. If something goes wrong with AAA repair, it goes REALLY wrong. The benefits seems to outweigh the risk of a central access.

Ahhh... grasshopper. This begs the question...

Which is faster route for replenshing fluids: infusing through a 9Fr introducer or a 14g peripheral IV (or better yet a RIC)?

The question itself should give you a clue. And, I definitively know the answer because I've done the experiment. 🙂

-copro

 

[coprolalia]

I think people generally overestimate the importance of central access. If you have a triple lumen catheter, your total flow rate (based on the rates actually printed on the package) buys you the equivalent of an 18g peripheral (that is, not so hot for resuscitation). Measuring central pressures is sometimes useful, but in the case of the AAA, you pretty much know what the deal is: hemorrhagic shock. If you insert an introducer, you obviously upgrade your flow rate considerably (an advantage which disappears if you fill that huge lumen with a pulmonary artery catheter). That said, a couple of 14s or an RIC can equal that flow rate without the complications of a central line, particularly if coagulopathy is part of the equation.

DING, DING, DING! I didn't read that far down before I posted. 😳

-copro