Aortic Surgery Anesthesia Management

Anesthetic Management of Aortic Surgery

• Utilize balanced anesthesia with an opioid, low-dose volatile anesthetic, benzodiazepine, and muscle relaxant for aortic surgery.
• Ensure controlled induction to prevent myocardial ischemia.
• Monitor for spinal cord function and blood supply during surgery.
• Prevent delayed neurologic deficits post-surgery.
• Address risk factors for renal failure after aortic surgery, including preexisting renal dysfunction, ischemia, and hypovolemia.
• Use strategies like retrograde distal aortic perfusion and pharmacologic agents for renal protection.

Spinal Cord Protection

• Emphasize the significance of collateral blood supply for spinal cord integrity during aortic surgery.
• Prevent delayed neurologic deficits post-surgery.
• Focus on optimal arterial blood pressure and cerebrospinal fluid drainage to prevent neurologic deficits.
• Predominantly, the anterior spinal artery supplies the spinal cord, and its protection is vital during surgery.

Coagulation Management

• Coagulopathy is a common occurrence during aortic surgery.
• Monitor coagulation factors during massive transfusion to prevent dilutional coagulopathy.
• Early use of fresh frozen plasma and platelets is necessary to avoid severe coagulopathy.

Endoleaks

• Endoleaks are a common complication in aortic procedures, characterized by persistent blood flow within the aneurysm sac after stent-graft placement.
• Early identification of endoleaks is crucial to prevent aneurysm expansion and rupture.
• Treatment options include observation, embolization, and revision of the stent-graft or conversion to open repair.

Anesthetic Technique for Hybrid Arch Repairs

• Precise deployment of stents at short proximal landing zones near the arch vessels is crucial to prevent complications like stent migration.
• Rapid ventricular pacing (RVP) is preferred for inducing hypotension during stent deployment.
• Anesthetic techniques involve a careful balance to maintain hemodynamic stability and prevent complications during the procedure.

Hemodynamic Management

• Hemodynamic and metabolic changes associated with aortic cross-clamping are complex and dynamic.
• The choice of anesthetic technique and management of hemodynamics play a critical role in the overall outcome of aortic surgery.
• Decrease in total-body oxygen consumption by approximately 50% occurs during thoracic aortic cross-clamping.
• Increased mixed venous oxygen saturation occurs due to reduced oxygen consumption exceeding the reduction in cardiac output.
• Arterial blood pressure, blood flow, and oxygen consumption below a thoracic aortic cross-clamp decrease by 78% to 88%, 79% to 88%, and 62%, respectively, from baseline values.

Postoperative Challenges with Epidural Anesthesia

• Postoperative complications, including cardiovascular, pulmonary, and renal issues, have not shown significant differences based on the use of epidural techniques.
• Length of hospital stay, a key outcome variable, has not been consistently reduced with regional techniques in aortic surgery.
• Epidural opioids without local anesthetics can be used during aortic clamping, with local anesthetic administration post-aortic unclamping once hemodynamics stabilize.

Open Repair of the Thoracoabdominal Aorta

• Open repair of the thoracoabdominal aorta is associated with significant morbidity and mortality rates.
• Paraplegia or paraparesis can occur in 3.8% to 40% of patients.
• Achieving normothermia and addressing hyperkalemia are crucial in postoperative management.

Coexisting Diseases

• Vascular surgery patients often have coexisting diseases, such as diabetes mellitus, hypertension, renal impairment, and pulmonary disease.
• Accurate clinical assessment of pretest probability of significant coronary artery disease (CAD) is essential.
• Continue usual cardiovascular medications, especially antiplatelet therapy, and gradual titration of β-adrenergic blocker therapy over 7-10 days before surgery.
• Preoperative renal insufficiency predicts postoperative renal dysfunction.

Endoleak Management and Postimplantation Syndrome

• Type III Endoleak is a structural failure of the stent-graft, requiring immediate intervention with new stent graft insertion.
• Type IV and V Endoleaks are associated with graft porosity and sac enlargement, respectively.
• Treatment options for endoleaks include embolization through iliac or mesenteric arteries and surgical interventions.
• Postimplantation Syndrome (PIS) occurs after endovascular aortic procedures, characterized by fever, leukocytosis, and coagulopathy.
• Treatment of PIS involves supportive care with antipyretics and transfusions as needed.

Hybrid Arch Repairs

• Hybrid arch repairs incorporate TEVAR with conventional repair for aortic arch pathologies.
• Types I, II, and III hybrid repairs are utilized for complex cases.
• Hybrid arch repairs enhance aortic arch reconstruction in high-risk patients with comorbidities.

Importance of Preoperative Planning

• Collaboration between anesthesia and surgical teams is crucial for managing potential complications.
• Anesthesia must be tailored to the patient and surgical needs.
• Hemodynamic stability, renal, cerebral, and spinal cord protection must be maintained to avoid post-operative complications.

Learn about the anesthesia management strategies for aortic surgery, including balanced anesthesia, controlled induction, and post-operative care. Ensure spinal cord function and blood supply during surgery and prevent delayed neurologic deficits.