The anesthetic technique of choice for better outcomes in high-risk elderly patients undergoing endovascular repair of aortic aneurysms

Abstract

To the Editor: We read with great interest the recent article by Asakura et al. [1] and wish to comment on their retrospective study of an anesthetic technique for patients undergoing endovascular repair of aortic aneurysms (EVAR), which has improved patient outcomes. Their review of 31 patients points out that ‘‘locoregional’’ anesthesia was well tolerated and has advantages over general anesthesia. We concur with their findings, as their retrospective analysis of patient’s corroborates with our results [2–4]. Based on our studies involving more than 500 patients with aortic abdominal and thoracic aneurysms, dissections, and transections [2–4], monitored anesthesia care (MAC) technique consisting of an opioid (fentanyl) and local anesthetic infiltration of the groin area with an adjunctive ilioinguinal/iliohypogastric nerve block has positive outcomes in this high-risk population with multiple comorbidities. The advantages of this technique include shorter intensive care unit (ICU) stays and faster hospital discharges, thus significantly cutting cost. Patients experience better pain control leading to reduced use of perioperative opioids. Avoidance of airway instrumentation and inhalational agents provides smoother intraoperative hemodynamics, resulting in less cardiopulmonary complications [2–4]. In addition, an awake, responsive patient is readily treated in case of adverse reactions (namely, to contrast material) due to early detection of signs and symptoms than in a patient under general anesthesia [5]. Use of the ultrasound-guided nerve blocks by Asakura et al. [1] was the only remarkable difference from our approach. Although the authors’ references are recent and do not site information from years past, their study substantiates what we have stressed over the years in the anesthesia and surgical literature. In conclusion, the efficacy of local anesthesia with MAC plus the adjunctive use of groin nerve blocks is an excellent alternative to general anesthesia and has previously been established in larger prospective clinical trials.