Open Conversion Abdominal Aortic Endograft in Thoracic Epidural Anesthesia alone in Patient with Severe COPD: A Case Report of Surgery in awake Patient and Review of the Literature

Abstract

A 79-year-old male was referred, with open abdomen surgical indication, for an asymptomatic iuxtarenal abdominal aortic aneurysm and type I endoleak with distal migration of an endovascular aortic – bisiliac prosthesis, after an endovascular correction done eight years before. This patient has several comorbidities such severe COPD (Stage IV and oxygen dependent), chronic kidney disease (G4 KDIGO CKD classification), systemic arterial hypertension and severe peripheral vasculopathy. Spirometry gives a picture of severe obstruction: FVC 2,44 L (68%), FEV1 0,68 L (25%), TLC 7.72 L (118%), RV 4,88 L (181%). 3 L/min oxygen arterial blood gas was: pH 7,34, PaO2 74,9 mmHg, PaCO2 51,2 mmHg, HCO3- 24,3 mEq/L, BE – 0,2, SpO2 94,2%. Cardiological consultation did not found any problem (normal ejection fraction, no valvular pathologies, and no pulmonary hypertension). Vascular echography highlighted an aortic aneurysm, confirmed by computed tomography angiography: iuxtarenal abdominal aortic aneurysm of 68 mm × 72 mm extended for 70 mm (Figure 1). According to the European Society of Anesthesiologists guidelines [1,2], general anesthesia is not safe, because of the elevated perioperative risks of severe respiratory complications. After a collegial respiratory risk evaluation, we have decided for an awake surgery with an epidural anesthesia. Operative risks were assessed with the patient who accepted intervention.