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5.4 Perioperative Management
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5.4.5.9 Short Stay EVAR
Studies
Shaw etal. [106] aimed to examine evidence for the safety and utility of a short stay
care pathway for EVAR.Inclusion criteria were asymptomatic patients, favourable
anatomy, patient consent, technical success, able to mobilise post-operatively, transfer time to hospital if readmission <60min, and adult observer for rst 24h. From
ve suitable studies, 450 (75%) patients were successfully discharged the same or
next day after EVAR.Complications most often occurred within 3h of surgery, and
major complications requiring intensive treatment unit admission occurred within
6h. Readmission rates were 0–5% for those discharged early, with no difference in
30-day readmission. Early discharge led to a statistically signicant cost saving of
£13,360 (LOS 4days) to £9844 (LOS 1day).
The objective of a retrospective, single-center cohort study presented by Montross
etal. [107] was to assess the possibility of developing a preoperative prole to select
potential candidates for ambulatory admission with early discharge (≤6h after surgery) or to have EVAR performed in a free-standing ambulatory surgery center
(ASC). Analysis of 272 elective endovascular aortic aneurysm repairs (EVAR)
cases revealed that failed percutaneous EVAR (odds ratio, 2.37) and percutaneous
EVAR performed outside of the manufacturer’s instructions for use (odds ratio,
2.84) were risk factors associated with ambulatory EVAR ineligibility. Early discharge after EVAR is possible in more than one-half of patients, permitting ambulatory hospital admission and discharge. However, preoperative proling is not yet
sufcient to endorse performing EVAR at free-standing ambulatory surgery centers
at this time.
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5.4.6 Ruptured Abdominal Aortic Aneurysm (rAAA)
5.4.6.1 Anaesthesia forEVAR
The ESVS guidelines [1] recommend:
• Recommendation 67: Local anaesthesia should be considered as the anaesthetic
modality of choice for endovascular repair of ruptured abdominal aortic aneu-
rysm whenever tolerated by the patient. (Class IIa; Level B)
Studies
Mouton et al. [108] reported on 3101 patients with rAAA captured in the UK
National Vascular Registry. 2306 underwent on open procedure and 795 had EVAR
(local anaesthesia, LA, n = 319; general anaesthesia, GA, n = 435; regional
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5 Abdominal Aortic Aneurysm (AAA)
anaesthesia, RA, n=41). Overall, 56 of 72 hospitals (78%) offered LA for EVAR
of rAAA.Patients who had surgery under LA had a lower in-hospital mortality rate
than patients who received GA (18.5% vs 28.0%), and this was unchanged after
adjustment for factors known to inuence survival (adjusted hazard ratio 0·62;
P=0·003). Median hospital stay and postoperative morbidity from other complications were similar. The study provided further evidence of the benet of LA for
patients undergoing emergency EVAR for rAAA.
Using the Vascular Quality Initiative database, Faizer etal. [109] compared LA
vs GA in EVAR for rAAA.Among 3330 patients with rAAA, 226 (6.8%) underwent EVAR in LA and 1510 (45.3%) underwent EVAR in GA.Hospital mortality
rates were signicantly lower with EVAR in LA compared with EVAR in GA
(15.5% vs. 23.3%; p=0.04). Patients undergoing EVAR who were <75years old
and those without preoperative hypotension had the greatest survival benet from
LA compared with GA.
Propensity score matching techniques were used by Bennett etal. [110] to compare the 30-day postoperative outcomes of patients from the 2007 to 2015 American
College of Surgeons National Surgical Quality Improvement Program database who
underwent endovascular repair of rAAA under locoregional vs general anaesthesia.
130 general anaesthesia patients were well matched with their locoregional anaesthesia counterparts. The 30-day postoperative mortality rates for patients in the
matched cohort were 14.6% for patients in the locoregional anaesthesia group compared with 29.2% for patients in the general anaesthesia group (P=.002).
The rst meta-analysis focusing on the effect of the anaesthesia modality on
perioperative mortality in endovascular repair of ruptured abdominal aortic aneurysms was performed by Deng etal. [111]. A total of eight studies were included in
this analysis. Three different pooled analyses of the data from the included studies
revealed robust results that endovascular repair of ruptured abdominal aortic aneurysms (REVAR) under locoregional anesthesia is associated with a lower 30-day/
in-hospital mortality than REVAR under general anaesthesia. However, because the
included studies may have had some observation bias, further randomized controlled trials are warranted to validate these results. Despite the perioperative survival benet of REVAR under LA vs GA observed, clinicians must exercise caution
when adopting this procedure. LA was associated with some potential disadvantages, including patient anxiety, discomfort, and movement artifacts caused by pain
or un-intubated respiration. In addition, awake patients might have a limited tolerance of time on the operating table, which increases the urgency of the REVAR.These
factors may result in inaccurate or incorrect deployment of the stent grafts.
5.4 Perioperative Management
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5.4.6.2 Access Type forEVAR inRuptured Abdominal Aortic Aneurysms
Studies
Cheng etal. [112] identied 1206 patients with EVAR for rAAA in the VQI database. 739 (61.3%) EVARs were performed by percutaneous access, 416 (34.5%) by
open access, and 51 (4.2%) by failed percutaneous that converted to open access.
Percutaneous access, compared with open access and failed percutaneous access,
respectively, had the shortest operative time (min, median) (111 vs. 138 vs. 180,
P<0.001) and was most often performed under local anesthesia (16.7% vs. 5% vs.
9.8%, P<0.001). Multivariable analysis did not show access type to have a signicant effect on cardiac complications, pulmonary complications, any complications,
return to the operating room, or perioperative mortality. However, open access was
independently associated with a prolonged length of stay (P=0.012). Access during
these emergent procedures should be based on surgeon preference and experience.
5.4.6.3 Permissive Hypotension
The ESVS guidelines [1] recommend:
• Recommendation 66: In patients with ruptured abdominal aortic aneurysm, a
policy of permissive hypotension, by restricting uid resuscitation, is recom-
mended in the conscious patient. (Class I; Level B)
Studies
In the management of people with rAAA, controlled hypotension resuscitation aims
to replace sufcient uid to maintain the blood pressure between 50 and 100mmHg
during the preoperative and intra-operative period. The controlled hypotension
strategy avoids large volumes of crystalloid replacement. It may help to prevent
blood loss by avoiding: the clot disruption caused by a rapid increase in systolic
blood pressure; the dilution of clotting factors, platelets, and brinogen; and the
temperature decrease that inhibits enzyme activity involved in platelet and clotting
factor function. The principle of controlled hypotension is widely adopted for people with trauma and has been applied for people with rAAA.A Cochrane Review
[113] found no RCTs that compared controlled hypotension and normotensive
resuscitation strategies in the management of haemorrhagic shock in patients with
ruptured abdominal aortic aneurysm that assessed mortality, presence of coagulopathy, intensive care unit length of stay, and the presence of myocardial infarct and
renal failure. In conclusion, high quality studies that evaluate the best strategy for
managing haemorrhagic shock in ruptured abdominal aortic aneurysms are required.
NICE published an evidence review on permissive hypotension during transfer
of people with rAAA to regional vascular services [114]. Although there was a lack
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5 Abdominal Aortic Aneurysm (AAA)
of evidence on permissive hypotension during transfer of people with ruptured
AAA, the committee noted that a recommendation in the clinical guideline on
assessment and management of major trauma (NICE guideline NG39) recommended the use of restrictive approaches to volume resuscitation in this population.
They agreed that the rationale underpinning the use of restrictive uid rescuscitation
in people after major trauma was applicable to people with ruptured AAA, as both
groups experience profuse bleeding. As a result, the committee considered it reasonable to adapt the recommendation from NICE guideline NG39 so it can be used
within the context of AAA.Excessive uid resuscitation can dilute clotting factors,
cause hypocalcaemia and reduce a patient’s body temperature. The committee
agreed that a potential benet of a permissive hypotensive resuscitation strategy is
that it can make surgery easier by reducing the size of haematomas. Furthermore,
patients will retain the ability to form clots, making postoperative management easier.
5.4.6.4 Aortic Occlusion Balloon
The ESVS guidelines [1] recommend:
• Recommendation 68: Aortic balloon occlusion for proximal control should be
considered in haemodynamically unstable ruptured abdominal aortic aneurysm
patients undergoing open or endovascular repair. (Class IIa; Level C)
Studies
Karkos etal. [115] aimed to investigate whether the use of aortic occlusion balloon
(AOB) has an impact on mortality of patients undergoing endovascular repair of
ruptured abdominal aortic aneurysms. Included in this meta-analysis were 39 eligible studies reporting 1277 patients. The pooled perioperative mortality was
21.6%. A total of 200 patients required AOB with an estimated pooled proportion of
14.1%. There was a statistically signicant negative correlation between AOB and
mortality and a positive effect of hemodynamic instability on mortality. In practical
terms, mortality was signicantly higher in studies with a higher proportion of
hemodynamically unstable patients and lower in studies with a higher rate of AOB
use. The study provided meta-analytical evidence that the use of an AOB in unstable
rAAA patients undergoing endovascular repair may improve the results.
5.4.6.5 Abdominal Compartment Syndrome
The ESVS guidelines [1] recommend:
• Recommendation 71: In all patients undergoing open or endovascular treatment
for ruptured abdominal aortic aneurysm, monitoring of intra-abdominal pressure
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for early diagnosis and management of intra-abdominal hypertension/abdominal
compartment syndrome is recommended. (Class I; Level B)
• Recommendation 72: In the presence of abdominal compartment syndrome after
open or endovascular treatment of ruptured abdominal aortic aneurysm, decom-
pressive laparotomy is recommended. (Class I; Level B)
• Recommendation 73: In the management of open abdomen following decom-
pression for abdominal compartment syndrome after open or endovascular treat-
ment of ruptured abdominal aortic aneurysm, vacuum assisted closure system
should be considered. (Class IIa; Level B)
Studies
A population-based Swedish study described the incidence, treatment, and outcome
of abdominal compartment syndrome (ACS) after rAAA [116]. ACS developed in
6.8% after OR versus 6.9% after EVAR.In the rAAA group, the 30-day mortality
rate with ACS was 42.4%. Without ACS, the 30-day mortality rate was 23.5%.
There was no difference in mortality between EVAR and OR among those who
developed ACS.After rAAA and OR the mortality rate was 37.5% at 30days, the
corresponding mortality rates after EVAR were 50% at 30 days. In all, approximately 14.9% (10.7% prophylactic treatment + 4.2% after decompression laparotomy) required open abdomen treatment after rAAA repair. Thus, ACS is a
devastating complication after rAAA repair, regardless of whether an open or endovascular technique is used. This knowledge is particularly important given the fact
that ACS developed as often after EVAR as after OR (although prophylactic open
abdomen treatment was common after OR).
In a second Swedish study, during 2008–2015, 120 of 8765 patients undergoing
surgery for infrarenal AAA developed postoperative ACS (1.4%). Among 1718
repairs for rAAA and 7009 repairs for iAAA, the risks of ACS were 45/1212 (3.7%)
after OR for rAAA, 38/506 (7.5%) after EVAR for rAAA, 307/2859 (1.0%) after
OR for iAAA, and 7/4150 (0.2%) after EVAR for iAAA [117]. The duration of
intraabdominal hypertension before treatment predicted the need for renal replacement therapy. This emphasises the need to focus on prevention, through careful
monitoring of intra-abdominal pressure, strategies for pre-emptive treatment of
intraabdominal hypertension, and swift treatment when ACS develops.
The aim of a propensity-matched retrospective cohort study was to investigate
whether leaving the abdomen open with delayed closure can improve outcome in
terms of mortality and major complications in patients treated for rAAA with open
repair, compared to closing the abdomen at the end of the primary operation [118].
In total, 79 patients treated with a primarily open abdomen were compared to a
control group of 148 patients. There was no difference in 30-day mortality between
patients treated with a primarily open abdomen and the controls, 21 (26.6%) versus
49 (33.1%), p=0.37. No difference was observed between the groups regarding
90-day mortality, postoperative renal failure requiring renal replacement therapy,
postoperative intestinal ischaemia necessitating bowel resection or postoperative
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bleeding requiring reoperation. Therefore, this study did not lend support to routine
use of open abdomen treatment after surgical rAAA repair.
5.4.6.6 Colonic Ischemia After rAAA Repair
Sigmoidoscopy
Jalalzadeh et al. [119] determined the value of sigmoidoscopy to detect colonic
ischaemia (CI) after repair of ruptured abdominal aortic aneurysm. Sigmoidoscopies
were carried out based on clinical judgment. Endoscopy results were classied as
“no ischaemia,” “mild CI,” or “moderate to severe CI.” In 43 of 351 patients (12%)
any grade of CI, as detected by sigmoidoscopy or laparotomy, was diagnosed. The
study suggested that the diagnostic value of sigmoidoscopy to detect CI after rAAA
repair is high in patients with a clinically moderate suspicion of CI.First, it is effective in ruling out the presence of CI.Second, when doubts exist about the presence
of CI, the probability of identifying a patient with transmural ischaemia increases
from approximately 22–73% when moderate to severe CI is detected at
sigmoidoscopy.
Extraluminal pH Measurement
Postoperative surveillance to detect colonic ischemia using extraluminal pH measurement (pHe) was performed by Ersryd etal. [120] in 27 subjects who had undergone surgery for intact or ruptured abdominal aortic aneurysms. At the end of the
primary open AAA repair, before abdominal closure, a balloon catheter was tunneled through the abdominal wall of the left fossa, lateral to the inferior epigastric
artery, and placed in the peritoneal fold adjacent to the sigmoid colon. The balloon
was positioned in contact with the sigmoid serosa. The catheter was connected to a
Tonocap device (GE Healthcare, Helsinki, Finland), and the pCO2 was measured
inside the balloon catheter. Measurements of pHe using colonic tonometry indicated malperfusion in all four patients who had developed clinically signicant
CI. Extraluminal pH measurement is a promising technique for surveillance of
colonic ischemia after open abdominal aortic aneurysm repair, but larger studies are
warranted.
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5 Abdominal Aortic Aneurysm (AAA)
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