Locoregional anesthesia attenuates complications of emergent endovascular aortic repair
Martin Walsh, MS, Michael Soult, MD, Pegge Halandras, MD, Carlos Bechara, MD, Bernadette Aulivola, MD, Paul Crisostomo, MD.
Loyola University, Maywood, IL, USA.
Objectives:Emergent aortic pathology exhibits high morbidity and mortality despite continued advancement in endovascular abdominal aortic repair(EVAR) and thoracic aortic repair(TEVAR). General anesthesia(GA) poses numerous deleterious cardiovascular effects. During elective EVAR, local/regional anesthesia(LA/RA) when compared to GA may decrease operative time and length of stay(LOS). It remains unclear whether LA/RA demonstrates similar beneficial effects in high risk emergent or ruptured aortic pathology. We hypothesize that LA/RA compared to GA will attenuate mortality and cardiopulmonary complications during emergent or ruptured EVAR / TEVAR.
Methods:The ACS NSQIP between 2005 and 2016 was queried using CPT codes indicating emergent EVAR or TEVAR. Propensity score matching was conducted to balance co-morbidities between the GA and LA/RA cohorts. A subset analysis of ruptured aortic aneurysms was also studied and compared between cohorts. Operative variables and postoperative complications were compared using chi-square tests for categorical variables and paired t-testing for continuous variables.
Results:A total of 3,075 emergent TEVAR/EVAR were identified from the database query(Table 1). Postoperative myocardial infarction(MI) did not differ significantly between GA(3.6%) and LA/RA(6.7%)(p=0.17). However, GA compared to LA/RA did exhibit greater 30 day mortality in emergent endovascular aortic repair (23.7%vs13.4%,p<0.01) (Table 2) as well as the subset of aortic rupture (28.4% vs 13.5%,p<0.03)(Table 3). Furthermore, rates of ventilator dependence(10.3%vs0%,p<0.001), prolonged intubation >48 hours(15.0%vs6.7%,p<0.01), and operative time(157.7min vs 131.6min,p<0.01) were significantly higher in the GA cohort of emergent aortic pathology(Table 2). Similar worse outcomes were identified when comparing GA to LA/RA during ruptured aortic endovascular repair.
Conclusions:LA/RA demonstrates significantly decreased 30 day mortality, pulmonary morbidity, and operative time when compared to GA during emergent or ruptured EVAR/TEVAR. Postoperative MI did not differ. Further study is needed to stratify which patients may best benefit from locoregional anesthesia during emergent endovascular aortic repair.
Table 1.Baseline before propensity score matching.
| General Anesthesia (N=2,874) | Regional/Local Anesthesia (N=201) | P value | |
| Age (years) | 71.5 (12.6) | 76.2 (11.1) | <0.001 |
| Female (%) | 28.7 | 26.3 | 0.48 |
| DM (%) | 13.3 | 12.4 | 0.72 |
| Smoking (%) | 33.9 | 30.4 | 0.32 |
| Dyspnea (%) | 10.4 | 7.7 | 0.23 |
| Functional Status: Partially or Totally Dependent (%) | 14 | 10.8 | 0.21 |
| COPD (%) | 16 | 22.7 | 0.02 |
| CHF (%) | 3.4 | 2.1 | 0.3 |
| HTN (%) | 73.6 | 74.2 | 0.84 |
| Dialysis (%) | 2.9 | 2.6 | 0.77 |
| Steroid use (%) | 5.8 | 5.2 | 0.72 |
| Bleeding disorder (%) | 20.4 | 20.1 | 0.91 |
| Preoperative Transfusion | 13.7 | 11.9 | 0.47 |
Table 2.Emergent EVAR/TEVAR outcomes
| General Anesthesia (N=194) | Regional/Local Anesthesia (N=194) | P value | |
| Intra-/postoperative CPR (%) | 7.7 | 5.7 | 0.42 |
| Operative time (minutes) | 157.7 (SD: 86.9) | 131.6 (SD: 69.3) | 0.001 |
| Length of Surgical stay (days) | 9.8 (SD: 10.0) | 8.2 (SD: 8.0) | 0.55 |
| Length of Hospital stay (days) | 7.8 (SD: 7.9) | 8.3 (SD: 11.2) | 0.57 |
| Mortality within 30 days (%) | 23.7 | 13.4 | 0.01 |
| Superficial wound infection (%) | 3.6 | 2.1 | 0.36 |
| Pneumonia (%) | 7.7 | 7.2 | 0.85 |
| Pulmonary embolism (%) | 1.6 | 0.0 | 0.08 |
| Vent >48 hours (%) | 15.0 | 6.7 | <0.01 |
| Acute Renal Failure (%) | 6.7 | 4.1 | 0.26 |
| UTI (%) | 3.1 | 4.1 | 0.59 |
| CVA/Stroke (%) | 3.61 | 3.1 | 0.78 |
| Myocardial infarction (%) | 3.6 | 6.7 | 0.17 |
| DVT (%) | 1.0 | 2.6 | 0.25 |
| Septic shock (%) | 4.1 | 2.6 | 0.40 |
| Ventilator Dependency | 10.3 | 0.0 | <0.001 |
Table 3.Ruptured EVAR/TEVAR outcomes
| General Anesthesia (N=74) | Regional/Local Anesthesia (N=74) | P value | |
| Intra-/postoperative CPR (%) | 6.8 | 5.4 | 0.73 |
| Operative time (minutes) | 165 (SD: 88.9) | 130.3 (SD: 68.2) | 0.009 |
| Length of Surgical stay (days) | 13.3 (SD: 13.4) | 10.4 (SD: 11.5) | 0.68 |
| Length of Hospital stay (days) | 9.2 (SD: 9.2) | 7.6 (SD: 7.7) | 0.26 |
| Mortality within 30 days (%) | 28.4 | 13.5 | 0.03 |
| Superficial wound infection (%) | 1.4 | 5.4 | 0.17 |
| Pneumonia (%) | 13.5 | 9.5 | 0.44 |
| Pulmonary embolism (%) | 1.4 | 0.0 | 0.32 |
| Vent >48 hours (%) | 21.6 | 8.1 | 0.02 |
| Acute Renal Failure (%) | 9.5 | 2.7 | 0.09 |
| UTI (%) | 6.8 | 5.4 | 0.73 |
| CVA/Stroke (%) | 2.7 | 2.7 | >0.99 |
| Myocardial infarction (%) | 10.8 | 8.1 | 0.57 |
| DVT (%) | 2.7 | 1.4 | 0.56 |
| Septic shock (%) | 5.4 | 2.7 | 0.41 |
| Ventilator Dependency | 10.8 | 0.0 | <0.01 |
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