What is your anesthetic of choice for Endovascular AAA repair?

[Patron]

What is you anesthetic of choice for endovascular AAA repair. Do you always use a cenral line?

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[Arch Guillotti]

What is you anesthetic of choice for endovascular AAA repair. Do you always use a cenral line?

Don't usually put in a central line.

GETA, art line, large bore peripheral access.

 

[pd4emergence]

Same here, rarely if ever put in a cvl

 

[BLADEMDA]

Don't usually put in a central line.

GETA, art line, large bore peripheral access.

Agree. We have done many of them. GETA, A-live, Second IV (16G).

 

[bostonblaz]

Aline, IV. Usually start with a MAC.

 

[sevoflurane]

I have partners that do them under BP cuff, LMA and 18G.

These cases take about 2 hours or less. Minimal blood loss. Pretty darn stable all things considered.

That beeing said, I still go GETA, a-line and 1 good peripheral. I don't place a CVL for these.

 

[proman]

I have partners that do them under BP cuff, LMA and 18G.

These cases take about 2 hours or less. Minimal blood loss. Pretty darn stable all things considered.

That beeing said, I still go GETA, a-line and 1 good peripheral. I don't place a CVL for these.

All depends on the surgeon and the anatomy of the patient. I've had one with 2 liter blood loss and needing a femoral artery repair. You can do anything from local only to GETA. My preference is as above though, intubate, arterial line, good IVs or central if unable.

 

[drccw]

I intubate these patients mainly because if the fan is hit then it's one less thing to do....

NIBP and second large bore IV....

My surgeons place two arterial lines for these cases...

drccw

 

[Idiopathic]

PIV times two, MAC vs. GETA

 

[BLADEMDA]

All depends on the surgeon and the anatomy of the patient. I've had one with 2 liter blood loss and needing a femoral artery repair. You can do anything from local only to GETA. My preference is as above though, intubate, arterial line, good IVs or central if unable.

Since most of these cases go just fine all you need is.... MAC and our usual monitors. That said, I place an A-line and Second IV plus GETA just in case things don't go well.
After all, that is why we are there right? To minmize the risk as much as possible without increasing complications on our end.

I see no need to go to room air General or eliminate the arterial line at this point. Maybe, in about 5 years and a thousand more cases my opinion will change.

 

[Patron]

Thank you guys, I have a 87 with CAD scheduled tomorrow,he has a positive stress test refuses cardiac cath, but he is asymptomatic and normal echo. Would you do anything different beside controlling his HR,BP. Would you consider regional?

 

[sevoflurane]

We used to place epidurals for these in residency.

I don't place them in my current gig.

 

[proman]

Thank you guys, I think I will go for GETA and 2 IVs and aline. This patient is 87 has CAD, with positive stress test refuses cardiac cath, but he is asymptomatic and normal echo. Would you do anything different beside controlling his HR,BP. Would you consider regional?

I'm just curious what your plan was for this specific patient before you posted the thread?

 

[Patron]

I was asking in general. But I have a scheduled case tomorrow with this scenario. I do realize that anesthetic plan should be modified to patient factors. Never done this case with this particular surgeon I don't know how long it will take him, to be on the safe side I am planing on GETA . But theoretically a MAC or a spinal would be a good choice.

 

[proman]

I was asking in general. But I have a scheduled case tomorrow with this scenario. I do realize that anesthetic plan should be modified to patient factors. Never done this case with this particular surgeon I don't know how long it will take him, to be on the safe side I am planing on GETA . But theoretically a MAC or a spinal would be a good choice.

Given the listed comorbidities, this patient would get an arterial line and great IVs for anything more than a toe nail clipping. But that's just me.

 

[saratoga733]

For patients with CAD/depressed EF I find a LMA actually works quite well. After initial simulation ie cutdown/wires in place... often only a very little amount of volatile is required to run a 'light' GA. It is quite easy to titrate appropriate dose of narcotics and obviously no paralytics involved. They don't move as oppose to MACs and if you need to you can always convert to a GETA.

 

[sevo85288]

A review of 29,000 plus cases in EU showed a very small rate of serious intraop complications. I go with 2 PIVs, GA vs. MAC/local. Aline if pt CV status warrants it.

A systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm
D. Drury1, J. A. Michaels1,*, L. Jones2, L. Ayiku2
Article first published online: 20 JUL 2005

DOI: 10.1002/bjs.5123



(Meta-analysis. 29,000 patients across 606 studies. No report of rupture or intra operative death. Does not breakdown the types of anesthesia/lines, etc, Most common complication relevant to us is access artery injury 4%)

 

[sevoflurane]

A review of 29,000 plus cases in EU showed a very small rate of serious intraop complications. I go with 2 PIVs, GA vs. MAC/local. Aline if pt CV status warrants it.

A systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm
D. Drury1, J. A. Michaels1,*, L. Jones2, L. Ayiku2
Article first published online: 20 JUL 2005

DOI: 10.1002/bjs.5123



(Meta-analysis. 29,000 patients across 606 studies. No report of rupture or intra operative death. Does not breakdown the types of anesthesia/lines, etc, Most common complication relevant to us is access artery injury 4%)

This has been my experience in PP... and things have only become better over the last 6 years since this paper was published. 👍

I think promans 2L blood loss is very unusual. It is the aorta, and we are mucking around... so anything is possible, hence my a-line and ETT. I'm more than happy with 1 16g IV that runs like a champ. If a disaster comes along, I can use the 16G while I put in a cordis. The problem with the LMA is that at certain portions of the procedure, our surgeons like to hold respirations for their DSA and angio runs.

 

[proman]

This has been my experience in PP... and things have only become better over the last 6 years since this paper was published. 👍

I think promans 2L blood loss is very unusual. It is the aorta, and we are mucking around... so anything is possible, hence my a-line and ETT. I'm more than happy with 1 16g IV that runs like a champ. If a disaster comes along, I can use the 16G while I put in a cordis. The problem with the LMA is that at certain portions of the procedure, our surgeons like to hold respirations for their DSA and angio runs.

I completely agree. For me it would either be local/sedation light enough for breath holds or GETA. It's too hard to do breath holds with an LMA. That case with the 2L was from the femoral site, but I still wouldn't routinely put in a central line. A-line is much more likely.

Emergent EVARs are a different beast. I think the European experience supports doing those under local with a whiff of sedation. It's the most stable approach in someone who would probably tank with anything more. Having the endovascular aortic clamp and a surgeon who knows how to use it is also very important.

 

[Mman]

Used to do these cases under just spinal (or epidural) with light sedation so patient could cooperate with breath holds. I've found most of the time it's just easier to do GA with ETT, 2 IVs, and an a-line.

 

[cincincyreds]

Spinal if patient is a candidate. Otherwise general ETT, 2 large bore IVs, a line.

I had the you know what hit the fan a few years ago when the incompetent surgeon decided to put a hole in the aorta without realizing it. I asked him to open when I needed to give epi to get the BP up.

Live and learn.