Intraoperative management: endovascular stents

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Surgical repair of aortic aneurysms

Conventional repair of aortic aneurysms typically involves significant hemodynamic and metabolic stresses, particularly among patients who are usually elderly and have multiple comorbid conditions such as ischemic heart disease, hypertension, chronic obstructive pulmonary disease, diabetes, and renal dysfunction.

With the high risk of aneurysm rupture, the current standard of treatment of an aortic abdominal aneurysm (AAA) is open surgical repair. The natural history of an aortic aneurysm is

Anatomic considerations for endovascular stent placement

The choice of standard surgical repair or a minimally invasive endovascular approach is currently limited by institutional practices, availability of equipment and physician to perform each procedure, and patient-related considerations. In a large center that has experiences with both techniques, the choice can be based on the anatomic features of the aneurysm and the patient's comorbid conditions. With the endovascular approach, unlike open surgical repair, the first decision in selection of

Intraoperative management

Because of the technical aspects of the endovascular graft systems and the procedure, endovascular repair of an aortic aneurysm presents unique challenges for intraoperative management and development of a safe anesthetic plan. The procedure is less invasive, requires minimal anesthesia, and is less likely to induce hemodynamic stress; yet, it may still be associated with many of the same risks and complications of any aortic surgery, such as massive sudden blood loss because of aortic rupture.

Postoperative care

Postoperative recovery after an uncomplicated endovascular surgery does not routinely require the use of an ICU. The patients are typically advanced to a regular diet and are ambulatory on the first postoperative day. Analgesic requirements are minimal and can be managed with nonsteroidal anti-inflammatory medications or small boluses of opioids. Postimplantation syndrome related to a systemic inflammatory response to the graft material may occur, manifesting with fever, leukocytosis, and

Anesthetic techniques

As reported in 1991 by Parodi et al [9], the first intraluminal grafts were performed under local or limited epidural anesthesia. For the experimental procedure, these investigators selected five high-risk patients with serious comorbidity, such as severe chronic obstructive pulmonary disease, acute stroke, severe asthma, or an ejection fraction less than 20%. The authors suggested that the transfemoral approach allowed the procedure to be performed under local or limited epidural anesthesia

Complications of endovascular aortic surgery

The development of endoluminal therapies has introduced new treatment options but has also created complex issues regarding patient care. There are many ethical, scientific, and practice issues that must be considered with the introduction of any new surgical procedure. The new treatment should have morbidity and mortality rates lower than current therapies. With small clinical studies having a wide variation in outcome parameters, larger prospective studies are needed. In 1996, the EUROpean

What is the role of endovascular repair in patients considered unfit for conventional open repair?

The limited life span of this group of patients makes it difficult to assess long-term outcomes of this procedure. The life expectancy of any patient with significant comorbidity should be greater than 1 year to realize any benefit from the procedure. In a study of 381 patients considered unfit for open repair and anesthesia, patients with significant comorbidity had higher mortality rates from nonaneurysmal-related complications, with cardiac events the most significant [46]. Whether mortality

Summary

Anesthetic management for major vascular surgery is one of the most complex areas of practice in anesthesiology. Repair of aortic aneurysms involves significant hemodynamic and metabolic stresses, particularly in a population of patients that is usually elderly and has multiple comorbid conditions such as ischemic heart disease, hypertension, chronic pulmonary disease, diabetes mellitus, and renal dysfunction. The introduction of endovascular repair of aortic aneurysms has presented a unique

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