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5.4 Perioperative Management
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with a poorer 30-day prognosis after rAAA.The nding of an adverse outcome in
ASA users after rAAA has not previously been reported. In this study, only patients
who had open surgical repair or no repair after rAAA were considered. The adverse
outcome after rAAA among ASA users could likely relate to complications of
excessive bleeding due to ASA-induced altered coagulation or ineffective clotting in
the immediate perioperative period after rAAA.However, these results do not provide sufciently strong evidence to recommend against the use of ASA in patients
with asymptomatic AAAs, given that the anticipated general cardiovascular protective effect is considered to outweigh the risk of an adverse outcome if the patient
should suffer a rAAA.
5.4.1.4 Beta-blocker
The European Society of Cardiology (ESC) and European Society of Anaesthesiology
(ESA) guidelines [54] recommend:
• Pre-operative initiation of beta-blockers may be considered in patients scheduled
for high-risk surgery and who have ≥2 clinical risk factors or ASA status 3.
(Class II b, Level B)
• Pre-operative initiation of beta-blockers is not recommended in patients sched-
uled for low-risk surgery. (Class III, Level B)
The ESVS guidelines [1] recommend:
• Recommendation 43: Commencement of beta blockers is not recommended
prior to abdominal aortic aneurysm repair. (Class III, Level A)
Studies
Hajibandeh etal. [55] performed a systematic review of the literature and metaanalysis of reported outcomes to evaluate the effect of beta blockers on perioperative outcomes in patients undergoing vascular and endovascular surgery. The results
of their analyses indicated that perioperative beta-blocker use did not reduce the risk
of all-cause mortality, cardiac mortality, MI, unstable angina, stroke,
arrhythmias,CHF, composite cardiovascular events, renal failure, rehospitalisation,
or reoperation in vascular surgery. Perioperative use of beta-blockers should not be
routinely used in vascular and endovascular surgery.
The objection to the cautious recommendations of the ESC [54] is that they are
not specically designed for the AAA.Alshaikh etal. [56] assessed the effect of
perioperative beta blocker (BB) use on postoperative in-hospital mortality after
open repair of abdominal aortic aneurysms. Of 6515 patients admitted for OR, 5423
(83.2%) received perioperative BBs. Patients who received BBs were more likely to
develop major adverse events compared with those who did not (45.6% vs 35.2%;
P<0.001); however, failure to rescue was lower among BB users (7.6% vs 19.5%;
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P<0.001). In a multivariable logistic regression model, BB use was associated with
57% and 81% lower odds of mortality among patients without and with a history of
coronary artery disease, respectively. The predicted mortality (95% CI) for patients
who did not receive BBs, or received low, intermediate, or high-intensity BBs was
11.6% (8.0%–15.2%), 5.4% (4.4%–6.5%), 2.5% (1.9%–3.0%), and 3.3%
(2.3%–4.3%), respectively. They concluded that in-hospital use of BBs was associated with a signicant reduction in postoperative mortality after OR.This was the
rst study to demonstrate a dose-response relationship between BBs and postoperative mortality after OR.Randomized studies are necessary in order to be able to
make a denitive recommendation.
5 Abdominal Aortic Aneurysm (AAA)
5.4.2 Preoperative Coronary Revascularisation
5.4.2.1 Guidelines
The Society for Vascular Surgery practice guidelines [2] recommend:
• In patients with signicant clinical risk factors, such as coronary artery disease,
congestive heart failure, cerebrovascular disease, diabetes mellitus, chronic renal
insufciency, and unknown or poor functional capacity (metabolic equivalent
[MET]<4), who are to undergo OR or EVAR, we suggest noninvasive stress
testing. [Level of recommendation 2 (Weak); Quality of evidence B (Moderate)]
• We suggest coronary revascularization before aneurysm repair in patients with
acute ST-segment or non-STsegment elevation myocardial infarction (MI),
unstable angina, or stable angina with left main coronary artery or three-vessel
disease. [Level of recommendation 2 (Weak); Quality of evidence B (Moderate)]
The ESVS guideline [1] recommend:
• Recommendation 29: In patients with stable coronary artery disease, routine
coronary revascularisation before elective abdominal aortic aneurysm repair is
not recommended. (Class III; Level B)
• Recommendation 30: In patients with unstable coronary artery disease or consid-
ered to be at high risk of cardiac events following abdominal aortic aneurysm
repair, prophylactic preoperative coronary revascularisation should be consid-
ered. (Class IIa; Evidence Level B)
5.4.2.2 Studies
McFalls etal. [57] randomly assigned patients at increased risk for perioperative
cardiac complications and clinically signicant coronary artery disease to undergo
either revascularization or no revascularization before elective major vascular surgery. The primary end point was long-term mortality. Coronary-artery
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revascularization before elective vascular surgery did not signicantly alter the
long-term outcome. On the basis of these data, a strategy of coronary-artery revascularization before elective vascular surgery among patients with stable cardiac
symptoms cannot be recommended.
The prognostic implication of coronary revascularization (CR) on overall and
cause-specic mortality in vascular surgery patients was determined by Ultee etal.
[58]. A total of 1104 patients were included in this retrospective study. The study
conrmed the signicance of ischaemic heart disease (IHD) for postoperative survival of vascular surgery patients. CR was associated with lower IHD-related death
rates. However, it failed to provide an overall survival benet because of an increased
rate of cardiovascular mortality unrelated to IHD.
This conrms the results of the randomised DECREASE (Dutch
Echocardiographic Cardiac Risk Evaluation Applying Stress Echo)-V trial. In this
trial, preoperative coronary revascularisation did not lead to improved postoperative
and long-term survival compared to “best medical therapy” in high-risk vascular
surgery patients with extensive stress-induced ischaemia [59, 60].
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5.4.3 Preoperative Carotid Intervention
5.4.3.1 Guidelines
The ESVS guidelines [1] recommend:
• Recommendation 40: Routine screening for asymptomatic carotid stenosis prior
to abdominal aortic aneurysm repair is not recommended. (Class III; Level C)
• Recommendation 41: Patients with abdominal aortic aneurysms and concomi-
tant symptomatic carotid stenosis within the last 6months should be considered
for carotid intervention before aneurysm repair. (Class IIa; Level A)
• Recommendation 42: Routine prophylactic carotid intervention for asymptom-
atic carotid stenosis prior to abdominal aortic aneurysm repair is not recom-
mended (Class III; Level C)
5.4.3.2 Studies
There are no specic studies on this issue in patients with AAA.Sonny etal. [61]
tested the primary hypothesis that degree of carotid artery stenosis is associated
with in-hospital stroke or 30-day all-cause mortality after noncardiac surgery. As
carotid artery stenosis is also a marker for cardiovascular disease, the secondary
hypothesis was that degree of carotid artery stenosis is associated with postoperative myocardial injury. Adults who had noncardiac, noncarotid surgery at Cleveland
Clinic from 2007 to 2011 and had carotid duplex ultrasound performed either within
6 months before or 1 month after surgery were included in this study. Of 2110
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patients included, 112 (5.3%) died within 30days and 54 (2.6%) suffered postoperative in-hospital stroke. There was no association between carotid artery stenosis
and perioperative stroke or 30-day mortality after noncardiac surgery.
5 Abdominal Aortic Aneurysm (AAA)
5.4.4 Open Repair ofNonruptured AAA
5.4.4.1 Perioperative Antibiotic Prophylaxis
The ESVS guidelines [1] recommend:
• Recommendation 46: In all patients undergoing open or endovascular abdominal
aortic aneurysm repair, peri-operative systemic antibiotic prophylaxis is recom-
mended. (Class I; Level A)
5.4.4.2 Fast Track Concept (ERAS)
The ESVS guidelines [1] note:
• Early or “enhanced” recovery after surgery (ERAS) programmes have been
designed to accelerate the postoperative recovery of surgical patients by reducing
the surgical stress response. The methodology of ERAS has been well estab-
lished in colorectal surgery and other areas of general surgery. A limited number
of studies have assessed ERAS protocols in the context of open AAA surgery
and have reported shorter hospital stays and decreased pulmonary
complications.
Studies
McGinigle etal. [62] performed a systematic review to characterize the use and
effectiveness of ERAS in all types of vascular and endovascular operations. In the
nal analysis, 19 studies were included. Twelve studies provided information on the
effectiveness of ERAS-like clinical care pathways in aortic surgery. Combined,
these studies included 2107 patients. All studies used pathways involving epidural
analgesia, oral intake on the day of surgery or postoperative day 1, and ambulation
on postoperative day 1. In addition to these elements, two studies also allowed
intake of clear liquids up to 2h before surgery and limited postoperative intravenous
uid to 1L/day; two other studies included scheduled metoclopramide in the postoperative period. Although the risk of bias is high in most of the studies done to
date, all of them observed improvements in length of stay, postoperative diet, and
ambulation. It is reasonable to consider the implementation of ERAS pathways in
the care of vascular surgery patients, specically those undergoing open aortic
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Table 5.3 Fast-track (“Enhanced Recovery After Surgery”, ERAS) protocol in open abdominal
aortic aneurysm repair (according to [63])
Protocol elements Element description
Preoperative
Counselling Meeting with a trained nurse at least 3weeks prior surgery.
Modication of risk factors. Informative booklet
Avoidance of fasting Intake of uids up to 2h and solids up to 6h before surgery
Carbohydrate loading 800mL of 12.5% maltodextrin-containing clear drink on the
preceeding evening+400mL up to 2h before anaesthesia
Intraoperative
Avoid central venous
catheter
Active normothermia Forced-air cover, warmed i.v. uids
Goal-directed uid Strictly controlled intraoperative uid administration according to the
Preemptive analgesia Preincisional subcutaneous inltration with lidocaine+ropivacaine
Avoid evisceration Positioning of self-retaining retractors for optimal access while
Avoid drainage
Postoperative
Opioid-sparing
analgesia
PONV prophylaxis Ondansetron (4–8mg i.v.)
Restrictive ICU Indicated only for high-risk patients depending on their pre- and
Early nasogastric tube
removal
Early urinary catheter
removal
Avoid prokinetic drugs
Early enteral feeding In the evening of the day of the surgery
Avoid i.v. hydration i.v. uid abolition immediately after the surgery
Early mobilisation 4h after surgery; assisted to sit in an armchair
ICU Intensive Care Unit, PONV Postoperative nausea and vomiting, NSAID nonsteroidal anti-
inammatory drug, POD postoperative day
Minimally invasive monitoring in radial artery
haemodynamic monitoring
avoiding evisceration
Perifascial analgesic catheter until POD 2, NSAIDs or paracetamol
upon request
intraoperative course; in-ward telemetry monitoring
At the end of surgery, before reversal of anesthesia
In the operating room at the end of surgery (or on the consecutive
morning)
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operations, but many of the details will be based on limited data and extrapolation
from other surgical specialties until further research is done.
A single centre’s experience with a fast-track protocol for open abdominal aortic
aneurysm repair (OR) was reported by Malik etal. [63]. The protocol (Table5.3)
was fully implemented in 103 patients, with a postoperative complication rate of 8%
across all and no deaths. Median hospitalization time was 3days, with only 17%
requiring ICU admission. Perioperative protocol implementation in AAA open
repair is feasible; the clinical outcomes may be improved when strictly adhering to
the protocol.
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5 Abdominal Aortic Aneurysm (AAA)
A single-center, prospective, nonrandomized cohort study with the use of the
enhanced recovery after surgery protocol in open abdominal aortic aneurysm repair
was presented by Giacomelli etal. [64]. During surgery, the ERAS patients were
administered a combination of thoracic epidural analgesia and short-acting anesthetic agents. The indwelling bladder catheter and nasogastric tube were immediately removed after AAA repair, and the central venous catheter and retroperitoneal
drain were removed on the rst postoperative day. The use of the ERAS protocol for
17 patients provided perioperative outcomes similar to those obtained for 18 patients
who had undergone endovascular aneurysm repair. Both groups had had a reduced
time to discharge and decreased postoperative pain compared with an historical
control group of 32 patients who had undergone open repair of AAAs with the standard protocol of care.
5.4.4.3 Epidural Anaesthesia
The Society for Vascular Surgery practice guidelines [2] recommend:
• We recommend multimodality treatment, including epidural analgesia, for post-
operative pain control after OR of an AAA.Level of recommendation 1 (Strong).
Quality of evidence A (High)
The ESVS guidelines [1] recommend:
• Recommendation 47: In patients undergoing open abdominal aortic aneurysm
repair, peri-operative epidural analgesia should be considered, to maximise pain
relief and minimise early post-operative complications. (Class IIa; Level B)
A NICE evidence review and guideline [65] noted that the identied evidence relating to elective open repair did not allow to draw many distinctions between the use
of general anaesthesia alone, general anaesthesia with an epidural, and general
anaesthesia with an intrathecal injection of opioid. However, the addition of an epidural to general anaesthesia was associated with a lower need for additional analgesia compared with the use of general anaesthesia alone. In the absence of explicit
contraindications, possible reasons not to undertake an epidural might include possible side effects (including cardiac, respiratory, or gastrointestinal complications),
the failure rate of epidurals, and the need for relatively intensive postoperative management to maximise benets of an epidural. However, the committee did not feel
that these concerns, when properly accounted for in the management of the patient,
outweighed the possible benets of using an epidural in conjunction with general
anaesthesia in people undergoing open repair of an unruptured AAA.The overall
recommendation was therefore positive.
The recommendation is different for ruptured AAA (rAAA). The committee
agreed that the use of epidurals in addition to general anaesthesia is not considered
safe or appropriate in the context of ruptured aneurysm. This is for a number of
reasons; including a lack of sufcient time to administer an epidural when a patient
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is losing blood quickly, as well as the fact that people with ruptured AAA are generally not in a condition to tolerate administration of an epidural.
Studies
Greco etal. [66] investigated the effects of supplemental epidural analgesia (EA) on
postoperative outcomes after open AAA repair using the National Surgical Quality
Improvement Program (NSQIP) database. A total of 2145 patients were included in
this analysis, of whom 1492 patients received general anesthesia (GA) only and 653
patients received EA-GA.Major postoperative outcomes included mortality, pulmonary cardiac and renal complications, infections, thrombosis, and blood transfusion requirement (including Cell-Saver usage). Additional overall outcomes
included hospital length of stay, return to the operating room, and readmission.
EA+GA was not associated with decreased mortality or decreased rates of major
postoperative pulmonary, cardiac, or renal complications. EA+GA was associated
with increased transfusion requirements and decreased rates of hospital readmission. The better pain relief provided by EA alone may justify its use.
5.4.4.4 Perioperative Pain Management
The Society for Vascular Surgery practice guidelines [2] recommend:
• Central regional opioids, systemic opioid patient-controlled analgesia, and
peripheral regional techniques are recommended for pain management, includ-
ing multimodal techniques such as central regional blockage with local anesthet-
ics. The geriatric population warrants special consideration, and incorporation of
acetaminophen is recommended in the postoperative pain plan.
Studies
Jessula etal. [67] compared the postoperative opioid intake in patients undergoing
open AAA repair across three analgesic modalities: systemic analgesia (SA) without regional anesthesia, paravertebral catheters (PVC) and thoracic epidural analgesia (TEA). Secondary objectives were to compare the time to discharge from the
ICU across analgesic modalities and to compare postoperative pain scores and the
opioid-related adverse event proles of PVC and TEA.Surgically positioned paravertebral catheters used for anesthesia in 117 of 355 patients undergoing abdominal
aortic aneurysm repair were associated with earlier discharge from intensive care
compared to patients who underwent only systemic analgesia; these patients had
similar rates of opioid-related adverse events than those who had thoracic epidural
anesthesia. The study contained limitations. Because PVC is feasible only through
a retroperitoneal incision, all patients in the PVC group had a retroperitoneal
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5 Abdominal Aortic Aneurysm (AAA)
incision and most patients in the TEA group had a transperitoneal incision (76.9%).
Because these two incision types may be associated with different pain proles, the
benets of PVC may be secondary to the incision type rather than the analgesic
modality.
Nejim etal. [68] reported on 6394 patients in the Premier Healthcare Database
who underwent elective OAR. 806 patients (12.6%) received the non-selective COX
inhibitor ketorolac. The study demonstrated 40% mortality reduction with intravenous ketorolac following open abdominal aortic aneurysm repair. Ketorolac use was
safe and was not accompanied by the expected NSAID-related side effects such as
postoperative hemorrhage, GI bleeding nor cardiac complications. The authors
explained the survival benet with the anti-inammatory and opioid-sparing properties of ketorolac. Limitations of the study include the potential selection bias
because the administration of ketorolac was not random.
5.4.4.5 Blood Transfusion andBlood Management
The Society for Vascular Surgery practice guidelines [2] recommend:
• In the absence of ongoing blood loss, we suggest a threshold for blood transfu-
sion during or after aneurysm repair at a hemoglobin concentration of 7g/dL or
below. Level of recommendation 2 (Weak). Quality of evidence C (Low)
The ESVS guidelines [1] recommend:
• Recommendation 49: Intra-operative cell salvage and re-transfusion should be
considered during open abdominal aortic aneurysm repair. (Class IIa; Level B)
NICE guidance [69]
• Consider alternatives to blood transfusion in surgical patients.
• Offer tranexamic acid to adults undergoing surgery who are expected to have at
least moderate blood loss (>500 mL). Do not use cell salvage alone without
tranexamic acid.
• For patients who need red blood cell transfusions and do not have major haemor-
rhage or acute coronary syndrome, use a restrictive haemoglobin concentration
threshold of 70g/L and a haemoglobin concentration target of 70–90g/L after
transfusion.
• Consider single unit red blood cell transfusions for patients who do not have
active bleeding and reassess patients after each transfusion.
Studies/Meta-analysis
A Cochrane review assessed the effectiveness and safety of anti-brinolytic and
haemostatic drugs and agents in reducing bleeding and the need for blood transfusion in people undergoing major vascular surgery or vascular procedures with a risk
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of moderate or severe (>500mL) blood loss [70]. Seven trials of three systemic
drugs (aprotinin, desmopressin and tranexamic acid) were identied. The trials of
aprotinin and desmopressin were small with very low-certainty evidence for all of
outcomes. Tranexamic acid versus placebo was the systemic drug comparison with
the largest number of participants (2 trials; 1460 participants), both at low risk of
bias. The largest of these included a total of 9535 individuals undergoing a number
of different higher risk surgeries and reported limited information on the vascular
subgroup (1399 participants). Neither trial reported the number of units of red cells
transfused per participant up to 30days. Three outcomes were associated with very
low-certainty evidence due to the very wide condence intervals (CIs) resulting
from small study sizes and low number of events. These were: all-cause mortality
up to 30days; number of participants requiring an allogeneic blood transfusion up
to 30days; and risk of requiring a repeat procedure or operation due to bleeding.
Most trials of topical drug treatments were at high risk of bias due to their openlabel design (compared with usual care, or liquids were compared with sponges).
All of the trials were small, and few reported clinically relevant outcomes in the
postoperative period. There is uncertainty whether any systemic or topical treatments used to reduce bleeding due to major vascular surgery have an effect on: allcause mortality up to 30days; risk of requiring a repeat procedure or operation due
to bleeding.
Red blood cell (RBC) transfusions are associated with increased mortality and
morbidity. The long-term effects of perioperative blood transfusions in patients with
elective open abdominal aortic aneurysm repair (OAR) were reported by Wedel
etal. [71] using data from The Danish Vascular Registry from 2000 to 2015. There
were 801 patients who did not receive blood transfusion among 3876 patients
(median survival 9.1years). Overall 30-day mortality was 3.1 and 3.6% for all
transfused patients. For ve subgroups 30-day mortality was: No transfusions 1.1%,
1 RBC 1.2%, 2–3 RBC 2.2%, 4–5 RBC 1.9% and >5 RBC 7.9%. After receiving
RBCs, the hazard ratio for death was 1.54 (95% CI 1.27–1.85) compared to nontransfused patients. There was a dose-dependent association between RBC transfusions received during elective AAA repair and an increase in short- and long-term
mortality. The conclusion was to set the transfusion trigger as low as possible in
OAR to avoid unnecessary blood transfusions. According to a Cochrane Review
[72], RBCs can be avoided in most patients with hemoglobin thresholds above
7–8 g/dL. There was no evidence that a restrictive transfusion strategy impacts
30-day mortality or morbidity.
Since open elective abdominal aortic aneurysm repair is associated with signicant blood loss, the intraoperative use of the cell saver (intraoperative autotransfusion) is recommended for these procedures. The cell saver should be used as
follows [73]:
• When anticipated blood loss is >1L or 20% of the patient’s estimated blood
volume (EBV)
• In patients with a low haemoglobin concentration or who are at increased risk of
bleeding
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5 Abdominal Aortic Aneurysm (AAA)
• In patients with multiple antibodies or rare blood types (cross-match compatible
blood is unobtainable)
• In patients who are unwilling to accept allogeneic blood (e.g., Jehovah’s
Witnesses)
• If>10% of patients undergoing the procedure will require transfusion
• If the mean transfusion requirement for the planned procedure exceeds one unit
of blood.
A systematic review on the role of cell savers in AAA surgery has been compiled by
Shantikumar etal. [74]. Twenty-three studies were identied. Whilst some data are
conicting, cell salvage appears to reduce overall use and exposure to allogeneic
blood and reduces length of intensive care unit and hospital stay after elective AAA
repairs. There may be additional benet by combining cell salvage with other bloodconservation techniques. Use of cell salvage in ruptured AAA repairs consistently
reduced blood-product requirement.
5.4.4.6 Graft Infection
The Society for Vascular Surgery practice guidelines [2] recommend:
• In patients presenting with an infected graft in the presence of extensive contami-
nation with gross purulence, we recommend extra-anatomic reconstruction fol-
lowed by excision of all graft material along with aortic stump closure covered
by an omental ap. Level of recommendation 1 (Strong). Quality of evidence B
(Moderate)
• In patients presenting with an infected graft with minimal contamination, we
suggest in situ reconstruction with cryopreserved allograft. Level of recommen-
dation 2 (Weak). Quality of evidence B (Moderate)
• In a stable patient presenting with an infected graft, we suggest in situ recon-
struction with femoral vein after graft excision and débridement. Level of recom-
mendation 2 (Weak). Quality of evidence B (Moderate)
• In unstable patients with infected graft, we recommend in situ reconstruction
with a silver- or antibiotic-impregnated graft, cryopreserved allograft, or PTFE
graft. Level of recommendation 1 (Strong). Quality of evidence B (Moderate)
The ESVS guidelines [1] recommend:
• Recommendation 77: For radical treatment of aortic graft or stent graft infection
complete graft/stent graft explantation is recommended. (Class I; Level C)
• Recommendation 78: In selected high risk patients with graft/stent graft infec-
tion, conservative and/or palliative options should be considered. (Class IIa;
Level C).
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