Anesthesia Management of Endovascular Repair of Aortic Aneurysm

Case Report

Austin J Anesthesia and Analgesia. 2014;1(1): 1002.

Anesthesia Management of Endovascular Repair of Aortic Aneurysm

Hong Wang*

Department of Anesthesiology, Wayne State University, Detroit Medical Center, USA

*Corresponding author: *Corresponding author: Hong Wang, Department of Anesthesiology, Wayne State University, Detroit Medical Center 3990 John R, Detroit MI 48201, USA.

Received: December 02, 2013; Accepted: December 23, 2013; Published: December 31, 2013

A Case Study

A 68-year-old female with tortuous aneurismal dilatation of the entire aorta with penetrating ulcers was scheduled for thoracoabdominal aneurysm endovascular repair. Her past medical history included previous abdominal aortic aneurysm (AAA) repair, coronary artery bypass, hypertension, Chronic Obstructive Pulmonary Disease (COPD), End Stage Renal Disease (ESRD), and active tobacco usage with 40 pack-year history. Due to the proximity of the stent deploy site and the origin of the aorta; adenosine was used to induce a 12-second asystole. A spinal drain catheter was placed and the pop-off pressure was 10 cm H2o to reduce the possibility of spinal cord injury. Transesophageal echocardiography (TEE) was used to guide the wires and estimate the endograft location. Due to the tortuous segmental dilation of the entire aorta, three different diameters of the aorta stents were deployed to fit the aorta. The patient was extubated at the end of the procedure and discharged from the hospital 5 days later. The following pictures show the aorta before and after the endovascular repair.


Endovascular repair of aortic aneurysms has gained popularity in recent years as a less invasive and potentially safer alternative to the open procedures. During the open procedures, the extensive periaorta dissection, significant fluid shift, prolonged aortic occlusion, and potentially significant blood loss lead to the relatively high operative mortality in comparison to the endovascular approach. However, this advantage from the endovascular approach is offset in the long term by graft-related complications.

The Class I indication of endovascular repair of aorta is degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms [1]. Candidates with multiple and significant comorbid medical conditions are often considered for endovascular repair.


Most aortic aneurysms can be treated by endovascular procedures if they meet the main technical criteria, including 20 mm of landing zone, distal vascular access, and limited tortuosity of the aorta.

Major adverse events related to endografts occur in 10-12% of patients in the initial 30-day perioperative period, with stroke rate between 2.5% to 8%, spinal cord ischemia in 1.5%, acute renal failure in 1.3%, and endoleaks in 10-20% of the patients [1]. Blood loss usually is not a serious concern. However, catastrophic bleeding does occur, but rarely. This could be due to the rupture of aneurysm or the retroperitoneal dissections to expose the external iliac artery.

Different approaches of this procedure have been developed. The retroperitoneal approach of abdominal aortic aneurysm (AAA) introduces the endografts through common iliac artery or aorta for patients with limited or no accessibility of the femoral artery [2]. Hybrid procedures for thoracic aortic aneurysm (TAA) and AAA have been developed for patients with aortic aneurysms involving major branches. These are exemplified by left carotid subclavian bypass [3], staged elephant trunk procedures [4], and aortic visceral debranching [5]. Although open surgical procedures are involved in these hybrid procedures, they are less invasive and involve less hemodynamic changes due to absence of aortic clamping. The open procedures can be staged or performed at the same time as endovascular procedures.

Most endograft patients have similar co-morbidities as open procedure patients. Some of them are not candidates for open procedures due to their coexisting conditions. The patients undergoing endovascular repair deserve the same extensive preoperative cardiac evaluation and intervention as recommended by the American College of Cardiology (ACC) and the American Heart Association (AHA) [6]. Whether the endovascular procedure should be classified as an intermediate or high-risk procedure is controversial due to the less hemodynamic change, fluid shift, and possibility of blood loss.

Citation: Wang H. Anesthesia Management of Endovascular Repair of Aortic Aneurysm. Austin J Anesthesia and Analgesia. 2014;1(1): 1002. ISSN: 2381-893X