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Increased Mortality and Pulmonary Morbidity with Endovascular Repair of Ruptured Abdominal Aortic Aneurysms Under General Anesthesia: A Population-Based Study
Jaime Benarroch-Gampel, MD, MS, Thomas J. Desmarais, MD, Gregorio A. Sicard, MD, Brian G. Rubin, MD.
Washington University School of Medicine, St. Louis, MO, USA.
OBJECTIVE: To determine if the incidence of death, myocardial infarction (MI), or pulmonary complications are different in patients undergoing endovascular repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) under general (GA) versus local and/or monitored care anesthesia (LA).
METHODS: 880 patients who underwent EVAR for a rAAA were identified from the National Surgical Quality Improvement Program database (NSQIP, 2007-2013). The association between type of anesthesia (GA vs LA) and incidence of perioperative death, MI and pulmonary complications was evaluated.
RESULTS: 798 (90.7%) patients received GA. This group was younger, more likely to be obese, had longer operative times (148 vs 125 min, P=.001) and length of stay (9.3 vs 7.2 days, P=.01) than patients who underwent LA. No differences in baseline ASA class or other comorbidities were seen between groups. Over the course of the study period there was a significant increase in the use of LA from 4.26% in 2007 to 12.98% in 2013 (P=.007). Overall, 19.5% of patients died, 6% had an MI, and 22.6% had pulmonary complications within 30 days of surgery. Postoperative mortality and pulmonary complication rates were higher in patients who underwent GA compared to LA (Table 1). In multivariate models adjusted for patient demographic, procedure and clinical characteristics, patients receiving GA were 2.2 times more likely to die (OR=2.22, 95% CI=1.06-4.69) or to have a pulmonary complication (OR=2.31, 95% CI=1.10-4.81) within 30 days of the procedure compared to those receiving LA. No differences between groups were found in the incidence of perioperative MI.
CONCLUSIONS: Our findings of a reduced mortality rate and pulmonary complications with LA compared to GA suggests that LA may be the safest anesthesia technique for patients undergoing EVAR for rAAA. Additionally, although the use of LA increased during the study period, it is not commonly used across participating institutions.
Table 1.- Univariate and Multivariate analysis of outcomes after EVAR for rAAA. | UNIVARIATE | MULTIVARIATE | | OR | 95% CI | OR | 95% CI | | DEATH | | Local ± MAC | Reference group | | General | 2.08 | 1.02 - 4.25 | 2.22 | 1.06 - 4.69 | | MYOCARDIAL INFARCTION | | Local ± MAC | Reference group | | General | 1.27 | 0.44 - 3.62 | 1.30 | 0.45 - 3.72 | | PULMONARY COMPLICATIONS | | Local ± MAC | Reference group | | General | 2.23 | 1.13 - 4.41 | 2.31 | 1.10 - 4.81 |
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