ANAESTHESIA FOR ENDOVASCULAR SURGERY (TEVAR AND EVAR)

INTRODUCTION
Abdominal abdominal aneurysm(AAA) are largely an incidental discovery during investigation of backache,hip pain or urinary tract complaints. Men:Woman 5:1 Surgery recommended when AP diameter >55mm Risk of spontaneous rupture depends on size : <1% per annum for AAA <55mm to >17% for AAA>60mm.

 1/3 of AAA have anatomical features suitable for endovascular repair. Endovascular surgery less invasive EVAR grown in popularity since 1990s. Aortic stent graft passed via femoral/iliac arteries under fluouroscopic guidance through aortic lumen to tightly fit above and below AAA. Stent cuts off systemic circulation from aneurysmal sac causinf sac to clot off or shrink with time.

Advantages
Minimally invasive Reduces blood loss (upto 60% less) Reduced stress response No aortic cross clamp necessary 30 day survival advantage Earlier ambulation with less pain Shorter hospital stay (50%) with less strain on ICU beds

Pre-operative Management
No different from a patient for open AAA repair Patients: Elderly Limited cardiorespiratory reserve High prevalence of CAD (pts assessed using AHA guidelines and EVAR falls in intermediate risk) Renal function must be assessed carefully as there is a risk of contrast induced nephropathy(CIN). Methods of reducing CIN are: -generous peri-op fluids - minimal use of contrast - increasing interval betweed contrast Ct angiography and EVAR - prophylactic use of antioxidants like N-acetylcysteine.

 Patients should be seen in Anaesthetic Clinic. If possible patients should be discussed with anaesthetist in charge of the list to avoid last minute cancellations. Anti-platelet (Clopidogrel) should be stopped 710days prior to surgery. Aspirin can be continued before surgery. Consent for anaesthesia taken with possibility of risks in case of conversion to open procedure explained.

Intra-operative Management
Patients prepared as per for open procedure (risk of conversion is 2%) Monitoring (ANZCA standards): - Arterial line essential. Placed on the right hand as surgeons may require access to left axillary artery if femoral artery is difficult. - CVP rarely necessary exception in patient with significant co-morbidities

- CBD necessary in order to monitor urine output as large amount of contrast used - Forecd air warming blanket maintained above nipple line Abdominal EVAR can be done under regional anaesthesia where in CSE is more appropriate (bearing in mind Heparin usage intra-op)

 Thoracic EVAR should be done under GA. IV Heparin 3000U usually given once femoral arteries exposed For patients under GA, anaesthetist will be asked to suspend resp during digital subtraction angiography is performed. Blood loss is 60% less and only 12% require blood transfusion. Care taken to examine concealed bleeding from femoral puncture sites.

 In cases of grafts which require balloon expansion, SBP should be maintained 80mmHg as a higher BP will cause stent to be displaced. Patients should be well hydrated due to the amount of contrast used. Evidence does not suggest the use of diuretics prevents CIN. In TEVAR, surgeon may request for a CSF drain with CSF pressure monitoring.

 CSF pressure ideally should be maintained <15mmHg ; if higher, CSF should be aspirated. All lumbar drains should be kept for 48hrs as neurological deficits occur during this period.

Post-Op Management
Patients should be nursed in an environment where arterial BP can be monitored. Hourly urine output necessary in view of CIN Most abdominal EVARs are stable enough to be nursed in the acute cubicle of the ward. Several studies have shown that hospital and ICU/HDU stay is reduced by 50% in EVAR patients.

TEVAR
Strict BP monitoring keep within 20% of patients baseline as there is a risk of graft migration. Monitoring of CSF pressure via lumbar drain. In event of a bloody tap, surgery will be delayed for 2hrs due to intra-op Heparin usage and associated risks of spinal/epidural hematoma.

 Monitoring neurology in event of neurological deficits, MAP should be increased with inotropes/pressors and CSF drained. Most neurologies are transient. Significant number will require coverage of Left subclavian artery stroke/upper limb ischaemia. Urgent carotico-subclavian bypass will be performed.

 All TEVARs require ICU No anti-coagulants except Aspirin or Clexane will be started in ICU in view of the lumbar drain

EVAR Complications
1. Endoleak -Persistent blood flow outside an endovascular graft but within the aneurysmal sac. - Immediate or delayed. - Incidence 18% 2. Maldeployment or Malposition of graft.

3. Post- implantation Syndrome - Fever,raised C-proteins and TWC in absence of infection

4. Rupture of iliac artery - more common in females due to smaller calibre of arteries and presents as refractory hypotension. - may require additional stent or conversion to open repair.

5. Stent Graft Limb Thrombosis - occurs within 24hrs and presents as lower limb ischaemia 6. Medical complications - ACS,ARF,CCF,Arrythmias,DVT,CVA,Resp infection