General Anesthesia Is Associated With Greater Hemodynamic Fluctuation But No Difference In Mortality During Endovascular Repair Of Ruptured Abdominal Aortic Aneurysms
Bowen Xie, MD, Dana Semaan, MD, Emely Carmona, Katherine Reitz, MD, MSc, Amanda Phillips, MD, MS, Elizabeth Ungerman, MD, MS, Nathan L. Liang, MD, MS.
UPMC, Pittsburgh, PA, USA.
Objectives: The use of local anesthesia/monitored anesthesia care (MAC) has been associated with reduced mortality during endovascular repair of ruptured abdominal aortic aneurysm (rEVAR/rAAA), but prior studies have been limited by lack of granular data. Our objective was to examine the hemodynamic effects of anesthesia modality in rEVAR patients. Methods: We retrospectively reviewed patients undergoing rEVAR at a multi-hospital healthcare system (2015-2020) and grouped them by anesthesia modality (general anesthesia, MAC, or MAC to GA conversion). Preoperative hemodynamic status was classified as stable (SBP>80 without vasopressors), moderate instability (SBP>90 with vasopressor use or any SBP<80 without vasopressors), or severe instability (SBP<90 with vasopressor use or preoperative CPR). Anesthetic agents were collected and defined as cardio-depressive if known to decrease systemic vascular resistance, or non-depressive. Primary outcomes included post-induction (within 20 minutes) SBP fluctuations or vasopressor usage and SBP nadirs. Secondary outcomes include 30-day mortality and post-operative in-hospital complications. Results: Of 219 rAAA, 123 (52%) were rEVARs with 9 patients excluded for pre-arrival intubation. GA was utilized in 76 (67%), MAC in 26 (23%), and MAC to GA conversion in 12 (11%). Patient demographics did not differ; however, pre-operative SBP was lowest among MAC to GA conversion and use of cardio-depressive induction agents was greatest for GA (Table 1). In the post-induction period, GA patients had significantly larger hemodynamic fluctuations at multiple time points (Table 1). Furthermore, in the post-induction period there was a significantly higher proportion of SBP nadirs (42% GA vs 4% MAC vs 36% conversion; p-value<0.001) and more frequent vasopressor usage (p-value<0.001) amongst GA patients. There were no significant differences in mortality (24% GA vs 19% MAC vs 42% conversion; p=0.29) or postoperative complications between modalities. Multivariable logistic regression analysis did not show a significant association between anesthesia modality and 30-day mortality when adjusting for presenting hemodynamic status, age, and sex. Conclusions: Patients undergoing GA for rEVAR demonstrated greater SBP fluctuations and peri-induction vasopressor usage but was not associated with a mortality difference compared to MAC in this cohort. A MAC-first approach may reduce hemodynamic volatility but effects of anesthesia modality on end-organ ischemia outcomes require further study. 
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