Locoregional Anesthesia Offers Improved Outcomes Following Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

Abstract

General (GA) and locoregional anesthesia (LA) are two anesthetic options for endovascular repair of ruptured abdominal aortic aneurysms (REVAR). Studies on EVAR of elective, intact aneurysms have indicated that in select patients, LA may provide improved outcomes compared to GA. We evaluated the 30-day outcomes in patients undergoing REVAR under GA and LA in a contemporary nationwide cohort of patients presenting with ruptured abdominal aortic aneurysmss. Patients who underwent REVAR under GA and LA from 2011 to 2015 were studied in the American College of Surgeons National Surgical Quality Improvement Program targeted EVAR database. Preoperative demographics, operation-specific variables, and postoperative outcomes were compared between the two groups. We identified 690 patients (80% male) who underwent REVAR, of which 12.5% (86) were performed under LA. Mean age was 74.3 years. Mean aneurysm size was 7.6 cm and did not differ between the two anesthetic groups. Major comorbidities and proximal or distal aneurysm extent also did not differ between the two groups except a slightly higher rate of congestive heart failure in the LA group (Table). There was a significantly higher rate of bilateral percutaneous access in the LA group (59.3%) than in the RA group (25.2%; P < .01). REVAR under LA had a shorter mean operative time (132 vs 166 minutes; P < .01) and a lower rate of concomitant lower extremity revascularization (2.3% vs 10.6%; P < .01). There otherwise was no difference in the need for other adjunctive procedures or perioperative transfusion. Ultimately, 30-day mortality was significantly lower in the LA group (16.3% vs 25.2%; P < .01). This was even more dramatic in the subgroup of patients with hemodynamic instability (15.4% vs 39.4%; P < .01). After adjustment, there was a twofold higher mortality in patients undergoing REVAR under GA vs LA, with a fourfold increase in the hemodynamically unstable cohort. The American College of Surgeons National Surgical Quality Improvement Program targeted EVAR database shows that LA is used in only 12.5% of patients undergoing REVAR in this nationwide cohort. This rate does not change when examining the subset of patients who are hemodynamically unstable. These data suggest that LA should be considered in patients undergoing REVAR regardless of hemodynamic instability.TableDemographics, operative details and outcomes of general anesthesia (GA) vs locoregional anesthesia (LA) for endovascular repair of ruptured abdominal aortic aneurysm (REVAR)VariableaREVAR-GA (n = 604)REVAR-LA (n = 86)P valueAge, years74.3 (10.4)74.6 (10.3).79Male79.5 (480)81.3 (70).68Body mass index, kg/m228.3 (6.8)28.2 (5.5).90Smoking33.6 (203)29.1 (25).40COPD19.9 (120)14.0 (12).19Congestive heart failure2.5 (15)7.0 (6).02Hypertension67.7 (409)72.1 (62).41End-stage renal disease3.0 (18)2.3 (2).74Proximal extent: infrarenal81.3 (491)86.0 (74).31Distal extent: aortic or common iliac57.0 (344)56.9 (49).99Access-bilateral percutaneous25.2 (152)59.3 (51)<.01Diameter.71 <5 cm7.9 (48)10.5 (9) 5-5.9 cm12.4 (75)10.5 (9) 6-6.9 cm11.8 (71)8.1 (7) 7-7.9 cm17.5 (106)16.3 (14) 8-8.9 cm11.6 (70)10.5 (9) 9-9.9 cm10.3 (62)14.0 (12) >10 cm11.3 (68)14.0 (12)Need for transfusion67.2 (406)61.6 (53).3030-day mortality25.2 (152)16.3 (86)<.01Length of stay Hospital, days9.1 (13.4)6.8 (6.1).12 Intensive care unit, days5.0 (6.7)3.0 (4.2).01Myocardial infarction6.3 (38)8.1 (7).52Pneumonia10.9 (66)3.5 (3).03Ischemic colitis7.8 (47)4.7 (4).30Unplanned readmission8.8 (53)10.5 (9).01Wound complication2.3 (14)1.2 (1).49COPD, Chronic obstructive pulmonary disease.aContinuous data are shown as mean (standard deviation) with the unit of measure and categoric data as percentage (number). Open table in a new tab