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3 Principles ofAnaesthesia inEndovascular Procedures
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Spinal Cord Perfusion Mean Arterial Pressure MAP Spinal C
Furthermore, maintaining spinal cord perfusion in the
perioperative period, particularly intra-operatively, and in
the immediate post-operative phase can reduce the risk of
spinal cord ischaemia. This can be readily achieved through
manipulation of the mean arterial pressure to a therapeutic
level of 90 or 100 mmHg (with vasopressor support). In
addition, other physiological parameters should also be optimised to assist in supporting blood pressure. This can include
aiming for a haemoglobin >100g/L [19].
Finally, insertion of a spinal drain can help control the
volume of cerebrospinal uid (CSF) and in turn spinal cord
pressure [20]. Drain insertion can either be done prophylactically (at the time of induction of anaesthesia, prior to surgery
commencing), or therapeutically, in the post-operative
period. As with all central neuraxial catheter insertions,
attention must be given to the timing of anticoagulation and
dual antiplatelet therapy.
Prophylactic Versus Therapeutic (Reactive)
Prophylactically inserting a spinal drain enables rapid management of deteriorating neurology, by allowing immediate
and controlled drainage of CSF to relieve pressure off the
spinal cord.
Therapeutic insertion avoids the risks of insertion of the
drain unless absolutely necessary, though risks insertion in
an anticoagulated patient (patients are heparinised intraoperatively), and possibly in difcult settings e.g. in critical
care with an agitated patient.
Spinal drains carry signicant risks to the patient, including post-dural puncture headaches, vertebral canal haematoma, infection, intracranial haematoma, and death.
Appropriate counselling must be offered for both the risk of
spinal cord ischaemia and spinal drain insertion prior to surgery [21, 22].
Ruptured Aneurysm
For this emergency procedure, anaesthetic considerations are
similar to elective procedures. Decision of anaesthetic technique will be guided by assessment of the patient’s clinical
parameters and pre-morbid state, likelihood to co-operate,
and anatomical concerns governing surgical approach.
Preferentially, a local anaesthetic technique with sedation
provides the most cardio-stable option but requires cooperation by the patient.
Anaesthetic considerations include massive blood loss
and associated transfusion; coagulopathy; electrolyte imbal-
oord Pressure.
ance; hypothermia; blood pressure control through glycerine
trinitrate infusion or vasopressor support.
The ideal location for this procedure is a hybrid theatre,
which can accommodate immediate conversion to an open
repair. There are some drawbacks, however. Such an environment may be remote to main theatres and unfamiliar to
non-vascular anaesthetic practitioners. Induction of anaesthesia must be done on the uoroscopy table, which cannot
tilt or be adjusted to a more desirable position for induction
of anaesthesia.
Post-operative Care
Analgesia
Due to the minimally invasive nature of endovascular treatment, post-operative pain is usually minimal. Simple analgesics may be sufcient. However, revascularisation of a limb
may lead to additional pain, such as reperfusion pain, that
requires stronger opiate-based analgesics. Severe postoperative pain may signify a vascular complication and
necessitates a review from the operating team.
Position
Initial patient position in recovery is determined by the site
of surgical access. If access was achieved via the groin, the
patient will need to be supine for at least 2h, or a duration in
keeping with local policy.
Level ofCare
Peripheral arterial and venous cases that require postoperative heparin infusions may require additional monitoring but for most patients, ward-based care is appropriate. All
endovascular aneurysm repairs will need critical care admission post-operatively for organ perfusion monitoring and
support. Complex EVARs, carry a greater perioperative risk
than infra-renal EVARS [23], including an increased risk of
renal impairment, post-operative blood transfusion, ventilator dependence, and increased length of critical care stay.
Patients with spinal drains need to be nursed in a level 2
monitored area with careful attention paid to the drainage
system and regular monitoring for neurological decits. It is
vital that practise is supported by management protocols that
are readily available and visible to all staff caring for these
patients.
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N. Khan et al.
References
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The Angiographic Suite: Setup
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andErgonomics
BowenXie andMichaelMadigan
4
Case Presentation
A 70-year-old gentleman with a history of coronary artery
disease status post coronary artery bypass grafts ×3 presented as a transfer to our institution for a ruptured infrarenal
abdominal aortic aneurysm with hypotension and back pain.
The patient arrived intubated and was brought emergently to
the hybrid operating room for endovascular repair. Both the
anesthesia and operative team were present in the operating
room to receive the patient on transfer.
Continued at page 28
Introduction
The use of minimally invasive interventions to treat vascular
disease has increased over the last few decades [1] due to
decreased length of stay and post-operative morbidity with
comparable results to open surgical procedures [2]. The
angiography suite now serves as the primary location for
vascular surgeons and other interventionalists to provide
appropriate and expedited care as a part of their clinical practice. Though endovascular procedures have shown benets
for patients, interventionalists must recognize and address
potential hazards associated with angiography and take the
necessary precautions to reduce radiation exposure and
workplace-associated injuries. This chapter serves to
describe the process of setting up an efcient and safe angiography suite, as well as coordinating care to maximize utility of the suite in a hospital system.
Layout
There are a variety of factors to consider when planning for
the installation of an angiography suite or hybrid operating
room (OR) including, but not limited to, location, room set up, adjunctive equipment, supplies, and imaging system [3,
4].
Location
Ideally, the angiography suite or hybrid room should be
placed either near other interventional suites or the ORs in
order to facility transportation of equipment, tools, and personnel. If the interventional suites are in a separate location
from the ORs, it is preferred that a hybrid room be located
next to the other ORs to allow for the immediate availability
of surgical instruments and equipment, as well as anesthesia
and operating room staff [5]. It is noted that this may not be
possible due to structural or engineering limitations of the
facility.
Room Set-Up
Booms
One or more moveable booms should be installed in order to
maximize working space, organize equipment, and improve
efciency. The moveable aspect of the booms allows for
exibility of the angiography suite in order to accommodate
various types interventions. Furthermore, the availability of
electrical outlets, connectors, and gas/air outlets also facilitate the workow. A separate boom may be necessary for the
anesthesia team in order to further improve efciency and
organization.
B. Xie · M. Madigan (*)
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
e-mail: xieb@upmc.edu; madiganmc@upmc.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_4
Lighting
It is important to have both appropriate surgical lighting as
well as ambient lighting during vascular interventional pro-
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B. Xie and M. Madigan
cedures. The lights will typically be ceiling mounted to
improve adjustability and provide adequate lighting during
open surgical approaches [6]. However, care must be taken
in order to avoid frequent collisions with the display monitors and the imaging system. The ambient room lighting
must provide the ability to dim as this is often helpful during
uoroscopy for improved visualization.
Monitors
Adequate imaging visualization is crucial in the setting of
endovascular procedures. As such, high-quality monitors are
essential for appropriate visualization by the operator and
the assistant personnel. Ceiling mounted monitors provide
the ability for greater range of motion in order to adjust and
improve operator ergonomics. Multiple monitors are
preferred to visualize the intervention as well as vitals and
anesthesia metrics during the procedure.
Operating Table
There are a variety of factors to consider with operating
tables. First, radiolucency of the table is necessary during
uoroscopic procedures with carbon ber being the preferred material due to its lightweight and radiolucent properties. Floating tabletops will provide the ability for fast and
precise movements during interventional procedures [7].
The addition of lead skirts surrounding the table will also
help to reduce radiation scatter to the operator and assistants.
Additional positioning aids, such as cushioned padding and
radiolucent arm boards, are also necessary for specic vascular interventions such as dialysis access interventions or
upper extremity uoroscopy. Finally, the addition of side
rails will allow for the mounting of surgical retractors that
are sometimes necessary for more extensive open surgical
interventions.
Storage
Adequate storage capacity with high-level organization is
imperative in the angiography suite in order to ensure quick
access to the necessary equipment and tools for a variety of
interventions. Built-in storage cabinets will not only reduce
workspace clutter, but also improve organizational design.
Commonly used sheaths, catheters, wires, balloons, stents,
closure devices and surgical equipment should be stored
within these cabinets for ease of access during both uoroscopic and hybrid procedures.
Control Room
The presence of a control room separate from the sterile
operating eld is ideal for additional visualization of images,
operative case planning, supervision, and observation for
trainees.
Adjunctive Equipment
Ultrasound
The use of ultrasound guidance for venous and arterial percutaneous access has been shown to reduce the incidence of
complications at the entry site [8, 9]. Furthermore, duplex
ultrasound is required for performance of certain interventions, such a venous ablation procedure [10].
Intravascular Ultrasound
The use of intravascular ultrasound serves as a important
supplement in the setting of venous as well as aortic dissection interventions due to its ability to provide intraluminal
visualization both pre and post-stent placement [4]. It is also
a necessary adjunct to performing interventions for iliac
venous occlusive disease [11]. Others have also suggested
benet for some peripheral interventions to more accurately
identify stenoses and to assist with sizing for angioplasty or
stent deployment [12, 13].
Power Injector
Utilization of a power injector allows for the operator to be
positioned further from the radiation source and thereby
reducing the exposure to the operative staff without sacricing image quality or intervention time [14]. In the case of
aortic imaging, the increased injection rate may also offer
improved timing and visualization of critical structures
while at the same time minimizing contrast load. The power
injector can be mounted onto the operating table for added
efciency.
Carbon Dioxide Injector
With the prevalence of chronic kidney disease and contrast
allergies within the population requiring vascular interventions, carbon dioxide (CO2) has established a role as a substitute for standard iodonated contrast. Therefore, the use of a
CO2 injector proves to be a necessary adjunct in modern day
vascular interventions [15].
Suction Thrombectomy Systems
Endovascular intervention for acute arterial and venous
thrombus are increasingly utilized in modern vascular interventions [16, 17]. With the development of catheter-directed
suction thrombectomy, there has been increased utilization
of this technology in the setting of acute limb ischemia, iliofemoral deep venous thrombosis, pulmonary embolism, and
even mesenteric or visceral vessel thrombosis. The purchase
of the suction thrombectomy system may potentially reduce
the long-term costs of repeat catheter-directed interventions
in exchange for an increased overhead cost of the initial
purchase.
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Commonly Used Supplies
In comparison to open surgical procedures, which utilize a
standard set of reusable instruments and clamps for most
cases, there is a signicant added cost to having adequate
disposable supplies for endovascular interventions.
Physicians within the system and practice should therefore
collaborate in order to standardize and simplify the necessary equipment and supplies. This can allow for in-bulk purchasing or contract agreements with supply companies to
reduce the cost of supplies. Table4.1 summarizes the broad
categories of necessary equipment and supplies needed for a
range of endovascular procedures [4].
Imaging System
There are a wide variety of imaging systems available for
use. Rather than focusing on the advantages and disadvantages of specic systems, this section will highlight various
features that may be important for optimal imaging during
endovascular interventions.
Mounting
A ceiling-mounted systems provides the benet of reducing
the amount of space occupied, however, this comes in
exchange for potential interference with lights, booms, and
monitors as well as the potential decreased sterility due to
dust or particle trapping within the system itself. Floormounted systems may occupy additional oor space, but can
Table 4.1 Commonly used equipment for various procedure types
Arterial and venous
interventions
Access needle, wire, and
micro sheath
Sheaths Cutting balloons Filter retrieval
Flush/marker catheters Tunneled dialysis
Selective/crossing catheters
and wires
Stiff working wires
Re-entry devices
Angioplasty balloons
Over-the-wire Fogarty
catheters
Snares
Drug-coated balloons
Bare metal stents
Covered stents
Drug-coated stents
Ination device
Coils/embolization devices
Closure devices
Dialysis
interventions Miscellaneous
High-pressure
balloons
catheters
Vena cava lters
kits
often times be moved during non-uoroscopic portions of
the operation and are suggested to be more hygienic by some
authors [3].
Image Detection
Most, if not all, xed imaging systems now come equipped
with at panel detectors, which produce higher image quality and resolution are compared to image intensiers, with
some systems providing resolution at four times the conventional systems (over 2000 pixels resolution) [18]. Flat panel
detectors also produce a larger eld of view, which may
prove to be essential in the setting of advanced endovascular
interventions, such as fenestrated endovascular aortic aneurysm repair. The dimensions of the at panel detector among
commonly used systems are 30×38cm for maximum eld
of view with certain broad detectors reaching up to
41 × 41 cm [18–20]. Additionally, these imaging systems
may be equipped with 3D fusion imaging and reconstruction
(i.e., EVAR Assist 2® from GE, SmartCT Angio® from
Philips, and EVAR-3D Guidance® from Siemens) [21–23] to
provide the ability to improve real-time intervention planning, to obtain real-time 3D image acquisition, as well as to
decrease radiation exposure, contrast volume, and operative
time by outlining vessels and optimizing angulation for precise device deployment.
The Benets ofaHybrid Operating Room
The advancement in endovascular technologies has helped
change the treatment paradigm of vascular therapy toward
novel approaches that require both open surgical and endovascular interventions to address complex vascular disease.
This approach has led to the development of a new working
environment [24]. An updated, conventional angiography
suite can aide in delivery of modern vascular care.
Furthermore, a number of studies have demonstrated that a
hybrid room with an endovascular suite integrated within a
traditional OR offers signicant benets over both a conventional angiography suite and the use of a portable C-arm
imaging system [25–27]. The benets of a hybrid OR and
limitations of a portable C-arm in a traditional operating
room are listed below in Tables 4.2 and 4.3. A hybrid OR
with an integrated imaging system provides the ability to
seamlessly perform open surgical procedures and endovascular procedures during the same intervention. Often, complex endovascular interventions are assisted by an open
surgical intervention, such as femoral endarterectomy, or
vessel exposure, such as a brachial artery cutdown, to allow
for endovascular interventions that would otherwise be difcult via a standard percutaneous approach. Furthermore,
the ability to convert to an open surgical intervention in setting of unanticipated access or other complications during
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Table 4.2 The benets of a hybrid operating room
Benets of a hybrid operating room
Sterility • Improved air circulation, positive air pressure
control to reduce air-borne contamination
• Optimal temperature and humidity control
• Easily washable ceilings, walls, and oors to
minimize potential harboring environment for
bacteria and blood-borne pathogens
Ability to
convert
Anesthesia • Adequate space for anesthetic equipment in
Table 4.3 Limitations of OR adaptations via portable C-arm system
Efciency • Reliance on additional personnel to operate
Imaging
capacity
Radiation
exposure
• Ability/equipment for immediate open surgical
conversion and treatment of suboptimal results/
complications
• Ability/equipment for direct surgical exposure
of artery/graft in anatomy unsuitable for
percutaneous access
cases extensive cardiopulmonary monitoring and
control
Limitations of a portable C-arm
portable equipment
• Difculty maneuvering portable equipment to
obtain optimal imaging angles
• Decreased image intensier size leading to
smaller eld of view
• Decreased monitor resolution and size of
displays in portable systems
• Decreased tissue penetration/image quality in
high complexity interventions
• Decreased projection angles of X-ray source/
image intensier leading to suboptimal
visualization of planes during complex
interventions
• Increased radiation scatter to operator due to x
image intensier distance in portable C-arm
systems
• Lack of available ceiling mounted shields and
table lead aprons to reduce scatter radiation
sia staff in order to maximize operative space and eld of
view. Multiple ultrasound machines are available for both
the anesthesia staff as well as the interventionalists to
establish intravascular access for resuscitation, intraoperative monitoring, and procedural access. A Foley kit and
bovie pads are also available for pre-procedural placement.
The angiography table is placed in a neutral position with
the monitor at, or below the eye level of the
interventionalist.
A micro-puncture vascular access kit has been opened
and prepped in anticipation of percutaneous access to the
common femoral arteries. In addition to basic wires
(hydrophobic and hydrophilic), both selective and ush
catheters have been opened and prepped in order to obtain
an aortogram. Sheaths of various sizes (5–8 Fr) are available with additional larger bore sheaths and stiff wires on
standby in case an aortic occlusion balloon is necessary
for proximal control. The remainder of the stent grafts,
closure devices and adjunctive supplies remain unopened,
but within the room for quick and easy access. Furthermore,
a tray of vascular surgical instruments along with bovie
and suction equipment have been laid out in anticipation
of potential open surgical exposure of access vessels in
the setting of poor anatomy for percutaneous access or
closure.
As highlighted by the clinical scenario, it is imperative
to have a trained team with experience in both endovascular and open interventions assisting in a hybrid procedure,
including circulating nurses, scrub techs, scrub nurses,
and interventional assistants, such as physician assistants,
residents, fellows, or surgical assistants in order to expedite the operative intervention and optimize patient
outcomes.
endovascular intervention provides an efcient manner to
address these potential issues. The well-controlled conditions within the OR also serve to improve sterility and potentially reduce the risk of infection of implantable devices [28].
A mounted system provides the benet of improved ergonomics and decreased radiation exposure to both the patient
and the operator due to the improved imaging capabilities
and safety measures when compared to the portable system
used as an adjunct in the OR.
Examples ofHybrid Room Set-Up
Below we provide an example of a set up during an endovascular aortic repair of a ruptured aneurysm in the hybrid
OR at our institution (Figs.4.1 and 4.2). The layout of the
hybrid room has been set up with the oor-mounted imaging system at the head of the table adjacent to the anesthe-
Fig. 4.1 Hybrid operating room design and set-up prior to endovascular abdominal aneurysm repair (EVAR)
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Fig. 4.2 Vascular intervention supplies and surgical instruments for EVAR
Coordination withOther Specialties
Given the high overhead costs of constructing an angiography suite or hybrid operating room and the potential
loss of revenue associated with only part-time use, it may
be essential to coordinate with other interventional services (i.e., interventional radiology, cardiology, and cardiac surgery) in order to maximize the utility of the room
with a variety of other interventional procedures such as
cardiac catheterization and transcatheter aortic valve
replacement. Therefore, an appropriate professional relationships should be established between various specialties in order to establish a comprehensive and
interdisciplinary environment for cardiovascular intervention and patient care.
Ergonomics
While signicant advances have been made in terms of radiation safety in the domain of uoroscopic interventions,
much less has been done to improve ergonomics.
Interventionalists are at a high risk of orthopedic injuries
often due to poor body mechanics and posture secondary to
the burden of protective equipment and the poor ergonomic
design of interventional suites [29–32]. Prior data from interventional radiologist and cardiologists have shown a high
incidence of spinal complaints (cervical, thoracic, and lumbar) as well as axial skeleton complaints with an association
to decreased longevity of their interventional careers [33].
This can contribute to work absences, poor overall health,
and even affect procedural outcomes.
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B. Xie and M. Madigan
Eect ofErgonomic Challenges
A recently published study of interventional cardiologist
demonstrated that approximately 9–33% of all participants
reported missing work days due to their musculoskeletal
complaints [34]. The increased need for leave of absences
interrupts the workow and may also lead to early retirement
thus decreasing the long-term workforce. This trend is similarly reected among vascular surgeons, with the majority of
those surveyed by the Society of Vascular Surgery reporting
pain after a day of open or endovascular procedures and a
signicant portion seeking medical care or even surgical
intervention [35]. Furthermore, there is growing evidence
suggesting that female surgeons and interventionalists are at
an increased risk of musculoskeletal injuries compared to
their male counterparts, particularly in the upper extremities
[36, 37]. Finally, the pain associated with musculoskeletal
injuries has been associated with self-reported burnout
amongst vascular surgeons in a study by Davila etal. [38],
which can have long-term detrimental physical and psychological effects on providers. Norasi etal. demonstrated both
the neck and the trunk were at high risk of developing musculoskeletal disorders due to awkward posturing during surgical procedures. There was a more prominent risk in open
operative procedures, especially when using visual aids such
as loupes [39].
Room Design
Adjustments within the operating and procedure rooms
must be tailored to maximize proceduralist ergonomics.
Display monitors during uoroscopic procedures as well as
other imaging adjuncts should be placed in front of the
interventionalist and in line with their shoulders allowing
for neutral neck position with a slight downward (15°) angle
thus reducing cervical spine strain [34]. Table height should
also be adjusted in order to minimize prolonged muscle activation. Studies have shown that table and hand positioning
at 70–80% of elbow height appears to reduce back discomfort [43]. Furthermore, additional adjuncts such as cushioned oor mats and the use of shoe insoles may also have a
preventative effect on axial skeletal strain. Figure4.3 demonstrates the example of ergonomics within the angiography
suite as highlighted by Knuttinen etal. [34] Table height is
adjusted according to the operator at near elbow height,
duplex ultrasound and display monitors are positioned in
the line of vision of the operator at a slight downward angle
to avoid excessive neck strain during the intervention.
Finally, while mobile lead shielding is essential in reducing
radiation dose, it is important to account for postural
changes involved in the use of the shielding in order to
reduce the incidence of ergonomically unfavorable positions. Ergonomic strategies are summarized in Table 4.4
[34].
Radiation Shielding
The term “interventional disc disease” has been developed
over the years to emphasize the trend of orthopedic workrelated complaints. These complaints were more prominent
amongst those using uoroscopy as compared to other operative surgical specialties not using uoroscopy suggesting a
correlation with chronic lead apron use [33]. Appropriate t
and weight distribution of lead garments are essential to
reduce the likelihood of musculoskeletal injury and fatigue.
The introduction of two-piece garments as well as wraparound lead has reduced axial strain and improved weight
distribution. Additionally, the transition to composite or
lead-free alternative protective garments further reduces
overall weight, however, there have been some reported differences in terms of the amount of shielding provided compared to their lead equivalents [40, 41]. The development of
a fully suspended radiation protection system equipped with
radiation shielding from head to calf that eliminates the
weight bearing component on the operator while maintaining mobility and maneuverability holds some promise for the
future [42].
Case Presentation
Continued from page 23
Once the patient was appropriately positioned with adequate access, his abdomen and groins were prepped in the
standard sterile fashion. Bilateral femoral artery access was
obtained simultaneously via micro-puncture access kits
under duplex ultrasound guidance. After appropriate sheath
placement, all operators moved to the right side of the patient
and the monitor and table were adjusted for optimal visualization. The room lights were dimmed appropriately to
improve visualization of the display without impeding the
scrubs techs’ abilities to prepare the instruments and devices
on the back table. The monitors were positioned at just below
operator eye level to reduce cervical strain during the intervention. Each operator and assistant also wore tted twopiece lead aprons to reduce thoracic and lumbar spine strain
during the procedure. The oating tabletop in the hybrid suit
allowed for rapid patient movement during the intervention
to adequately visualize both proximally into the aorta and
distally into the iliac arteries. A 32cm Medtronic Endurant®
endograft was deployed with iliac extensions bilaterally
(Fig.4.4). The storage capacity of the hybrid suite allowed
ab
4 The Angiographic Suite: Setup andErgonomics
https://t.me/medicina_free
Fig. 4.3 Proper ergonomic positioning during lower extremity angiography via right brachial approach, (a) side view of intra-procedural position-
ing with monitor in line of vision, table at elbow height and slight downward tilt of neck, (b) frontal view of intra-procedural posturing
Table 4.4 Ergonomic strategies to reduce the risk of musculoskeletal
injuries
Ergonomic strategies
Position monitor directly in front of the operator and in line with
shoulders
Position monitor height at a 15° downward viewing angle
Adjust table height to at or just below elbow level
Avoid repetitive truncal motions or prolonged truncal rotation
29
for rapid access to the necessary catheters and balloons to
ensure appropriate cannulation of endograft and deployment
of the iliac limbs. The use of a power injector along with the
improved magnication and resolution of the integrated
imaging system allowed for precise deployment of the endograft while minimizing contrast use and radiation. Both femoral accesses were closed with the pre-deployed ProGlides®
without complications, though surgical instruments were
opened and prepared in the hybrid suite for expedited femoral cutdowns and arterial repair in case of closure device failure. The patient was brought ICU for resuscitation and
recovery in stable condition. He was extubated on postoperative day one and only had a transient acute kidney
injury that resolved during his hospital course with
appropriate urine output throughout. He was discharged
home on post-operative day 6.
Acknowledgments Research reported in this publication was supported by the National Heart, Lung, And Blood Institute of the National
Institutes of Health under Award Number T32HL098036. The content
is solely the responsibility of the authors and does not necessarily represent the ofcial views of the National Institutes of Health.
Fig. 4.4 Completion angiography after successful EVAR of ruptured
abdominal aortic aneurysm
30
https://t.me/medicina_free
B. Xie and M. Madigan
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