AAA stent and anesthetic consideration

Presented by 劉志中

Patient profile

• 82y/o ,female• Past history: 1.DM 2.HTN for 40 years 3.CAD ,two vessels (RCA,LCX) s/p POBAS 4.paroxysmal Af with RVR 5. left renal artery stenosis s/p stenting

Present illness

2004/10 pulsatile abdominal mass ,echo and CT revealed AAA at 埔基2004/11 came to NTUH an episode of chest tightness with ST-T depression and T inversion over V4-6 on ECG, Af with RVR s/p codarone control2004/11 Cardiac cath:CAD,2VD s/p POBAS carotid duplex: bilateral carotid a. stenosis and vertebral a. flow insufficiency2005/1/6 AAA stent

Induction agent

• Fentanyl 100ug

• Atropine 0.5mg

• Etomidate 18mg

• Succinylcholine 70mg

• Cistracurium 10 mg+ continuous infusion

• NTG:0.1ml x 2

Intraoperative mantainace

• Sevoflurane

• Intermittent bolus : fentanyl (total dosage:150ug)

Op procedure

• ETGA ,supine

• Bilateral femoral a. cut-down and expose

• L. femeral a. sheath insertion and put into a pig tail

• R. femeral a. sheath insertion and put into the main body of AAA stent

• Expended the stent….

Video time

What we have to know

• Open vs. Stent graft

• What kind of patients will we meet ?

• Anesthetic plan

• Intraoperative monitoring and surgical complications

• Post operation care

Open vs.Stent-graft

• Open AAA repair is still the first choice of therapy currently

• While aged patient ,increased co-morbidity,

the cost and benefit of this traditional open

surgery should be weighed

An analysis of standard open and Endovascular surgical repair of AAA in Octogenarians• Endovascular surgical repair of AAA has

the advantages as follows:

1. less blood loss

2. shorter ICU stay

3. shorter hospital stay

4. less blood transfusion

5. less cardiopulmonary complicationsThe American surgeon 2003,Sep;744-748

What kind of patients will we meet ?

• The patient who presents for elective repair of an abdominal aortic aneurysm often has additional

1.hypertension (55%) 2.CAD (73.5%) 3.peripheral vascular disease (21%) 4.stroke and transient ischemic attack(22%) 5.DM(7%) 6.renal insufficiency (10%) 7.smoking history (80%)

Vasc Surg 2001;35:335-44

Anesthetic plan

• General vs. regional

No difference in overall cardiac and

pulmonary morbidity and mortality

J Vasc Surg 2002;36:988-91

• Appropriate monitoring :depends on patients coexisting disease.

• Central venous access

• Avoid cardiosuppression drugs as possibleAnesthesiol Clin N Am,22(2004)251-64

Intraoperative monitoring

• Pulse oximetry

• ECG (5 lead)

• A- line

• Foley

• Temperature

• CVP

• PAP

• TEE

Surgical complications

• Arterial injury ,device implant failed• Device occlusion,stenosis,migration• Endoleak

1.type I: inadequate seal at proximal of

distal segments of the endoprosthesis

2.type II:brach flow through patent accessory

renal,IMA,hypogastric,lumbar or sacral a.

3. type III: midgraft leak through a fabric hole or

inadequate seal between graft components Anesthesiol Clin N Am,22(2004)319-32

The risk of late failure is 3% per year, the continued presence of the risk of aneurysm rupture is 1% per year

Post op care

• Not routinely required ICU stay if uncomplicated• Prolonged mechanical ventilation may be indicat

ed if major intra-op bleeding, MI,renal failure,bowel ischemia,sepsis syndrome,or ARDS.

• Close hemodynamic monitoring• Adequate analgesia:opioid , NSAID,neuro-axial

block.• Postimplantation syndrome: fever,leukocytosis,a

nd increased CRP.

Thanks for your attention!!