Anesthesia for vascular surgery 2024.pptx

Anesthesia for Vascular Surgery: From Evaluation to Management Vicente Gonzalez, DNP, CRNA, APRN Florida International University Department of Nurse Anesthesiology Importance of Preoperative Evaluation in Vascular Surgery Assessing and Optimizing Understanding...

Anesthesia for Vascular Surgery: From Evaluation to Management Vicente Gonzalez, DNP, CRNA, APRN Florida International University Department of Nurse Anesthesiology Importance of Preoperative Evaluation in Vascular Surgery Assessing and Optimizing Understanding Systemic Perioperative Coexisting Diseases Nature of Atherosclerotic Management in Vascular Diabetes mellitus Disease Surgery Hypertension Comprehensive preoperative evaluation Understanding pathophysiology of vascular Renal impairment Systemic nature of atherosclerotic disease lesions Pulmonary disease Accurate clinical assessment of coronary artery disease Prudent use of preoperative cardiac testing Management of Prevention and Treatment Cardiovascular of Perioperative Medications Myocardial Ischemia Vital for successful outcomes Control of myocardial oxygen supply and Throughout perioperative period demand Initiating perioperative β-adrenergic blocker therapy Maintaining vital organ perfusion during aortic surgery Monitoring predictors of postoperative renal dysfunction 2 Assessing and Optimizing Coexisting Diseases in Vascular Surgery 1. 2. 3. 4. 5. High Importanc Systemic Coronary Managem Incidence e of Nature of Artery ent of Preoperati Atheroscle Disease Strategies Coexisting ve rotic (CAD) Understand Diseases Evaluation Disease Leading underlying pathophysiology Patients Focus on Atherosclero cause of. Accurate clinical undergoing assessing tic disease perioperativ assessment of vascular and in vascular e mortality CAD. surgery optimizing patients in vascular Use preoperative often have coexisting often surgery cardiac testing. diabetes diseases involves patients. Address mellitus, before multiple Significantly challenges of preoperative hypertensio surgery to vascular limits long- cardiac risk n, renal improve territories. term assessment. impairment, outcomes. survival Accurate risk assessment and and after management of pulmonary vascular coexisting 3 Systemic Nature of Atherosclerotic Disease in Vascular Patients Systemic Nature of Arterial Disease in Importance of Accurate Atherosclerotic Disease Multiple Vascular Clinical Assessment High prevalence of coronary artery disease Territories Crucial for prudent use of preoperative (CAD) in vascular patients Patients often have arterial disease in cardiac testing CAD is a leading cause of perioperative Helps in rational interpretation of test results multiple areas mortality Understanding pathophysiology is crucial in vascular surgery Guidelines on Comprehensive Approach Prophylactic Coronary to Cardiovascular Care Revascularization Systemic nature of atherosclerotic disease Rarely necessary to reduce perioperative or requires comprehensive evaluation Aims to reduce cardiovascular risks in long-term morbidity Medical therapy is important in managing vascular patients CAD 4 Perioperative Management in Vascular Surgery Preoperative Evaluation and Optimization Importance of preoperative evaluation in vascular surgery Assessing and optimizing coexisting diseases Understanding pathophysiology in vascular surgery Cardiovascular Considerations Clinical assessment of coronary artery disease Preoperative cardiac testing Management of cardiovascular medications Prevention of perioperative myocardial ischemia Intraoperative Management Maintaining vital organ perfusion in aortic surgery Cerebral monitoring in carotid endarterectomy Anesthesia considerations for abdominal aortic reconstruction General vs. epidural anesthesia in aortic surgery 5 Perioperative Management in Vascular Surgery Postoperative Care and Complications Predictors of postoperative renal dysfunction Effects of postoperative hypothermia Challenges of cardiac risk assessment Management of endoleaks in aortic procedures Advanced Techniques and Outcomes Use of stent-grafts in vascular surgery Monitoring techniques in thoracic aortic aneurysm repair Anesthetic management of hybrid arch repairs Outcomes of coronary artery bypass grafting in vascular patients Understanding Pathophysiology in Vascular Surgery Systemic Nature of Coronary Artery Disease Cardiovascular Atherosclerotic Disease (CAD) Medication Management Affects multiple vascular territories Leading cause of perioperative mortality in Essential for perioperative care in vascular Common in vascular patients vascular surgery patients surgery Accurate clinical assessment is crucial for Prevention and treatment of myocardial preoperative testing ischemia require control of oxygen supply and demand Perioperative β- Vital Organ Perfusion in Adrenergic Blocker Aortic Surgery Therapy Crucial for overall outcome Initiation should be cautious Predictors of postoperative renal dysfunction Titrated over 7-10 days include preoperative renal insufficiency 7 Clinical Assessment of Coronary Artery Disease in Vascular Patients 1. 2. 3. 4. 5. High Coronary Prophylact Perioperat Preoperati Incidence Artery ic ive ve and of Disease Coronary Medicatio Postopera Coexisting (CAD) Revascula n tive Diseases Leading cause of rization Managem Considerat perioperative Vascular surgery mortality in Rarely necessary to ent ions patients often have vascular surgery decrease surgical diabetes mellitus, risk unless Continue usual Gradual titration of patients. hypertension, renal Accurate clinical indicated. cardiovascular β-adrenergic impairment, and assessment of Medical therapy is medications, blocker therapy pulmonary disease. pretest probability the cornerstone for especially over 7-10 days of significant CAD is CAD management. antiplatelet before surgery. crucial. therapy. Preoperative renal Careful control of insufficiency myocardial oxygen predicts supply and demand postoperative renal is essential. dysfunction. Endovascular aortic surgery as a less invasive alternative with specific complications. Cerebral monitoring 8 during carotid Preoperative Cardiac Testing in Vascular Surgery Assessing Cardiac Risk Clinical Risk Indices Noninvasive Diagnostic Assessing cardiac risk in vascular surgery Utilize cost-effective screening methods to Cardiac Testing patients is crucial due to the high prevalence determine which patients may require Direct noninvasive testing towards patients of coronary artery disease (CAD) and the further cardiac evaluation. at intermediate clinical risk to optimize increased risk of myocardial infarction and Consider the high pretest probability of CAD preoperative assessment. death. in vascular surgery patients. Avoid unnecessary testing that may not alter patient management. Cardiac Catheterization Importance of Accurate and Prophylactic Risk Assessment Revascularization Use a systematic approach to accurately Consider the findings from studies like the assess the risk for cardiac morbidity. Maintain a cost-effective and evidence-based Hertzer series to guide decisions on prophylactic revascularization in patients strategy to reduce perioperative and long- undergoing vascular surgery. term cardiovascular risks. 9 Management of Cardiovascular Medications in Vascular Patients 1. 2. 3. 4. Continuing Perioperative Role of Statins Intraoperative Cardiovascular Myocardial Statins have shown promise Monitoring in preventing perioperative Medications Ischemia cardiovascular and Patients should continue Prevention and treatment of complications in vascular surgery patients. Anesthesia their usual cardiovascular perioperative myocardial The use of statins in the medications throughout the ischemia are crucial for Intraoperative monitoring perioperative period should techniques should be perioperative period. patient care. be individualized based on Antiplatelet therapy requires Initiation of perioperative β- selected based on patient patient factors. needs and accurate individualized consideration adrenergic blocker therapy Patients requiring ongoing and should be continued should be carefully titrated interpretation of data. statin therapy should Maintenance of vital organ based on patient needs. over 7-10 days before continue statins surgery. perfusion and function is perioperatively. crucial for overall outcomes in aortic surgery. The choice of anesthetic drug or technique should prioritize stable perioperative hemodynamics. 10 Prevention of Perioperative Myocardial Ischemia Importance of Strategies to Reduce Risk Maintenance of Stable Preoperative Assessment Accurate clinical assessment of coronary Hemodynamics Identify cardiovascular risk factors artery disease Prevent perioperative myocardial ischemia Optimize cardiovascular risk factors Utilization of preoperative cardiac testing Ensure myocardial perfusion Prophylactic Coronary Perioperative β- Revascularization Adrenergic Blocker Based on individual patient risk factors Therapy Reduce risk of myocardial ischemia 11 Perioperative β-Adrenergic Blocker Therapy in Vascular Surgery 1. 2. 3. 4. Continuation Tachycardia Dosing Impact on of Therapy Management Guidelines Preoperative Patients undergoing β-adrenergic blockers Acute initiation of large- Testing vascular surgery should should not be used as the dose β-adrenergic blockade continue taking β- initial or primary treatment in the perioperative period Perioperative β-adrenergic adrenergic blockers for tachycardia caused by should be avoided. blocker therapy can throughout the perioperative events. Therapy should be initiated decrease the number of perioperative period. with a small dose and patients referred for titrated over a 7- to 10-day preoperative cardiac period before surgery. testing. However, preoperative cardiac testing should not be eliminated, and its risk- to-benefit ratio should be carefully assessed. 12 Maintaining Vital Organ Perfusion in Aortic Surgery Importance of Factors Influencing Renal Protection Hemodynamics Surgery Strategies Stable perioperative hemodynamics are Factors influencing ventricular work and Preoperative renal insufficiency is a crucial in aortic surgery to ensure vital organ myocardial perfusion during aortic surgery. significant predictor of postoperative renal perfusion. Complex pathophysiology during aortic dysfunction. Emphasis on maintaining stable cross-clamping and unclamping, including Strategies for renal protection include hemodynamics over the choice of anesthetic effects on coronary artery disease, retrograde distal aortic perfusion techniques drug or technique for optimal outcomes. intravascular blood volume, and sympathetic and pharmacologic agents like mannitol and nervous system activation. dopamine. Adequate blood flow and arterial pressure Additional Considerations are essential to preserve renal function Systemic and regional hypothermia are during cross-clamping. needed to protect the kidneys during ischemia. Monitoring coagulation factors during massive transfusion is crucial to prevent coagulopathy and ensure optimal outcomes. 13 Predictors of Postoperative Renal Dysfunction in Vascular Patients Preoperative Renal Dysfunction Significant predictor of postoperative renal dysfunction in vascular surgery patients. Factors Contributing to Postoperative Renal Failure Ischemia during cross-clamping Thrombotic or embolic interruption of renal blood flow Hypovolemia and hypotension Incidence of Postoperative Dialysis Approximately 6% of patients undergoing aortic surgery may require postoperative dialysis due to renal failure. 14 Predictors of Postoperative Renal Dysfunction in Vascular Patients Cross-Clamp Time and Renal Protection Duration of cross-clamp time is crucial Retrograde distal aortic perfusion techniques widely used to preserve renal function Pharmacologic Agents for Renal Protection Mannitol improves renal cortical blood flow and glomerular filtration rate Dopamine utilized for renal protection Endovascular Aortic Surgery Considerations Precise Stent Deployment Hybrid Aortic Arch Repair Advanced Stent-Grafts Importance of precise stent deployment near Increasing frequency of hybrid aortic arch Focus on fenestrated stent-grafts (FEVAR) for arch vessels to prevent migration. repair procedures. complex abdominal aortic aneurysms. Utilization of rapid ventricular pacing during Associated risks with hybrid procedures. Use of multi-branched grafts (mBEVAR) for deployment to induce hypotension. complex cases. Endovascular vs. Open Anesthesia Planning Repairs Anesthesia planning tailored to the surgical Benefits of endovascular approaches over approach. Consideration of vascular access for optimal open repairs. Improved recovery times and outcomes with patient care. endovascular methods. 16 Cerebral Monitoring in Carotid Endarterectomy 1. Cerebral Monitoring in Carotid Endarterectomy Cerebral monitoring during carotid endarterectomy is crucial for identifying patients in need of carotid artery shunting. It helps in recognizing patients who may benefit from an increase in arterial blood pressure or a change in surgical technique. Cerebral monitoring plays a significant role in detecting potential complications and ensuring optimal outcomes during carotid endarterectomy procedures. 17 Effects of Postoperative Hypothermia in Vascular Surgery Undesirable Physiologic Importance of Normal Impact on Patient Effects Body Temperature Recovery Postoperative hypothermia is associated with Maintaining normal body temperature is Hypothermia can impact patient recovery. undesirable physiologic effects. crucial for improving outcomes in vascular Should be actively managed to prevent May contribute to adverse cardiac outcomes. surgery patients. complications. Optimizing Patient Outcomes Proper temperature control is essential for optimizing patient outcomes postoperatively. 18 Preoperative Testing in Vascular Surgery Patients 1. 2. 3. 4. Importance of Strategies for Key Guideline- Preoperative Effective Considerations Based Testing Preoperative Preoperative evaluation Approach plays a crucial role in Preoperative testing should Testing optimizing outcomes in Following guideline-based only be performed if it will vascular surgery. approaches for impact patient care. Assessing and optimizing The need for a cost-effective perioperative cardiovascular Challenges of cardiac risk coexisting diseases such as and evidence-based evaluation in noncardiac assessment in vascular diabetes, hypertension, strategy to decrease surgery. surgery patients. renal impairment, and perioperative and long-term Ensuring that preoperative pulmonary disease. cardiovascular risks. testing is performed Understanding the systemic Rates of myocardial judiciously to influence nature of atherosclerotic infarction and death in patient care effectively. disease in vascular patients. vascular surgery patients. Emphasizing the importance Accurate risk assessment in of accurate risk assessment vascular surgery patients. in vascular surgery patients. 19 Challenges of Cardiac Risk Assessment in Vascular Surgery Complexity of Cardiac Challenges with Risk Preoperative Assessment Risk Assessment Indices Tools High prevalence of coronary artery disease Used for screening Clinical risk variables (CAD) High pretest probability of CAD complicates Noninvasive cardiac testing Increased risk of myocardial infarction and assessment death Role of Cardiac Importance of Accurate Catheterization and Risk Assessment Revascularization Crucial for optimizing outcomes Based on study findings like the Hertzer Guides appropriate management strategies series Assesses severity of CAD in vascular surgery patients 20 Strategies to Reduce Cardiovascular Risks in Vascular Patients 1. 2. 3. 4. Guideline- Pharmacologic Prophylactic Perioperative Based Management Coronary Management Cardiovascular Initiating and optimizing Revascularizat Monitoring for perioperative pharmacologic myocardial ischemia and Evaluation management preoperatively ion initiating β-adrenergic to reduce perioperative and blocker therapy cautiously. Implementing a guideline- Considering prophylactic long-term cardiovascular Individualizing statin based approach for risks. coronary revascularization therapy for perioperative cardiovascular evaluation in Continuing cardiovascular based on findings from the cardiovascular vascular patients. medications throughout the Hertzer series. complications. Utilizing risk indices and perioperative period for Balancing the timing of dual noninvasive diagnostic optimal management. antiplatelet therapy in testing for accurate cardiac patients with coronary risk assessment. stents undergoing noncardiac surgery. Emphasizing the importance of maintaining stable hemodynamics and vital organ perfusion during aortic surgery. 21 Rates of Myocardial Infarction in Vascular Surgery Patients Short-term Follow-up Long-term Follow-up Persistent Prevalence Studies on short-term follow-up (in hospital Long-term follow-up (in hospital and after The prevalence of MI and death persists or 30-day) post-vascular surgery have discharge) data shows an average MI rate of despite aggressive medical and surgical reported an average myocardial infarction 8.9% and a death rate of 11.2% in vascular therapy in vascular surgery patients. (MI) rate of 4.9% and a death rate of 2.4%. surgery patients. Importance of Risk Assessment These rates underscore the importance of accurate risk assessment and appropriate management strategies to optimize outcomes in patients with vascular disease. 22 Accurate Risk Assessment in Vascular Surgery Utilize Clinical Risk Indices Initial screening of patients before vascular surgery Consider Coexisting Diseases High prevalence of diabetes, hypertension, renal impairment, and pulmonary disease in vascular surgery patients Assess Pretest Probability Accurate assessment of significant coronary artery disease for prudent use of preoperative cardiac testing Implement Vascular Surgery-Specific Risk Indices Optimize prediction of perioperative mortality and cardiac morbidity Combine Clinical Risk Variables with Noninvasive Testing Comprehensive preoperative cardiac risk assessment 23 Advanced Coronary Lesions in Peripheral Vascular Disease Prevalence of Advanced Unrecognized Cardiac Impact of Left Ventricular Coronary Lesions Conditions Systolic Dysfunction Patients undergoing vascular surgery often Unrecognized myocardial infarction (MI) and (LVSD) present with advanced coronary lesions. silent myocardial ischemia are common in LVSD is significantly more prevalent in Over 50% have advanced or severe coronary vascular surgery patients. patients with vascular disease compared to artery disease (CAD). These conditions are associated with controls. increased long-term mortality and adverse LVSD impacts perioperative outcomes. cardiac events. Importance of Medical Therapy and Risk Preoperative Cardiac Assessment Assessment Medical therapy is crucial in managing CAD Advanced coronary lesions in peripheral in vascular surgery patients. Accurate risk assessment and appropriate vascular disease patients underscore the importance of thorough preoperative cardiac perioperative care are essential. assessment. Management strategies are crucial. 24 Outcomes of Coronary Artery Bypass Grafting in Vascular Patients Prevalence of CAD in Vascular Patients Coronary artery disease (CAD) is highly prevalent in vascular surgery patients. Less than 10% have normal coronary arteries. Over 50% have advanced or severe CAD. Cardiac Risks in Vascular Surgery Unrecognized myocardial infarction (MI) and silent myocardial ischemia are common. Associated with increased long-term mortality and adverse cardiac events. Left Ventricular Systolic Dysfunction (LVSD) Significantly more common in patients with vascular disease compared to controls. Anesthesia and CABG Outcomes Success of CABG in vascular patients does not favor any specific type of anesthesia. Perioperative and long-term morbidity and mortality rates persist despite aggressive medical and surgical therapy. Choice of anesthesia does not significantly impact perioperative outcomes. 25 Outcomes of Coronary Artery Bypass Grafting in Vascular Patients Anesthesia Techniques and Considerations General anesthesia linked with increased pulmonary morbidity and longer hospital stays post-CABG. Lack of substantial evidence indicates one anesthetic technique is superior to another. Simple CABG procedures can be performed under local, regional, or general anesthesia. More complex procedures may require general anesthesia. Continuous advancements in endovascular repairs have led to decreased operative times. Prophylactic Coronary Artery Revascularization in Vascular Surgery Prophylactic Coronary Medical Therapy Guidelines on Coronary Artery Revascularization Medical therapy remains the cornerstone for Intervention Prophylactic coronary artery managing coronary artery disease in Guidelines recommend that coronary revascularization is not shown to reduce vascular surgery patients. intervention is rarely necessary solely to The focus should be on optimizing medical perioperative or long-term morbidity after decrease surgery risk unless indicated, major vascular surgery. therapy and managing cardiovascular risk regardless of the preoperative context. Prophylactic coronary revascularization has factors in these patients. not been proven to reduce perioperative or long-term morbidity in vascular surgery patients. Perioperative Management Patients should continue their usual cardiovascular medications throughout the perioperative period. Preoperative cardiac testing should be done judiciously based on the pretest probability of significant coronary artery disease. 27 Perioperative Strategies for Reducing Myocardial Infarction Guideline-Based Approach Implement a guideline-based approach for perioperative cardiovascular evaluation in vascular surgery patients. Utilize risk indices and noninvasive diagnostic testing to assess cardiac risk before surgery. Cardiac Catheterization and Revascularization Consider cardiac catheterization and prophylactic revascularization based on findings from the Hertzer series. Optimize preoperative assessment of cardiac risk with clinical risk variables and noninvasive cardiac testing. Risk Assessment and Management Focus on accurate risk assessment and appropriate management strategies to decrease perioperative and long-term cardiovascular risks. Address the high prevalence of coronary artery disease in vascular surgery patients and the increased risk of myocardial infarction and death. 28 Perioperative Strategies for Reducing Myocardial Infarction Medical Therapy and Challenges Emphasize the importance of medical therapy in managing coronary artery disease in vascular patients. Highlight the challenges of preoperative cardiac risk assessment in vascular surgery patients and the need for evidence-based strategies. Cost-Effective Strategies Ensure a cost-effective and evidence-based strategy to decrease perioperative and long-term cardiovascular risks. Coronary Angiographic Classification in Vascular Patients Importance of Accurate Prevalence of Advanced Implications of Clinical Assessment Coronary Lesions Unrecognized Myocardial Essential for identifying coronary artery High prevalence in patients with peripheral Infarction disease in vascular surgery patients vascular disease Can lead to severe perioperative Helps in planning appropriate surgical Often underdiagnosed due to lack of complications interventions symptoms Silent myocardial ischemia is common in Reduces the risk of perioperative Requires thorough diagnostic evaluation vascular surgery patients complications Early detection is crucial for better outcomes Role of Prophylactic Strategies for Reducing Coronary Artery Perioperative Myocardial Revascularization Infarction Helps in managing coronary artery disease Preoperative risk assessment and effectively optimization Reduces the risk of perioperative myocardial Use of beta-blockers and statins infarction Close monitoring during and after surgery Should be considered in high-risk patients 30 Long-Term Survival in Vascular Patients 1. 2. 3. 4. 5. Long-Term Mortality Neurologic Renal Other Survival Rates Complicati Complicati Complicati Rates Mortality rates for ons ons ons elective TAA repair Long-term survival were reported at Paraplegia or Renal failure rates Gastrointestinal rates in vascular 19% at 30 days. paraparesis occurs range from 3% to complications occur patients 31% at 365 days in in 3.8% to 40% of 30%. in approximately undergoing surgical a large statewide TAA repair patients. Approximately 6% 7% of patients, with repair of series. Extensive of patients need a mortality rate thoracoabdominal dissecting TAA postoperative approaching 40%. aortic aneurysms repair carries the dialysis after TAA Pulmonary (TAA) range from highest risk for repair, associated complications are 5% to 14% in large neurologic deficit. with mortality rates common, with institutions. of 30% to 60%. postoperative Statewide and pulmonary nationwide rates insufficiency rates potentially higher nearing 50%, and at around 20%. 8% to 14% of patients requiring tracheostomy. Cardiac complications are frequent and a leading cause of perioperative mortality in TAA 31 repair patients. Risk of Renal Ischemia in Aortic Surgery Preexisting Renal Ischemia During Cross- Strategies to Preserve Dysfunction Clamping Renal Function Significant predictor of postoperative renal Crucial factor contributing to postoperative Retrograde distal aortic perfusion is failure after aortic surgery. renal complications. commonly used. Adequate bypass flow and arterial blood pressure are essential. Hypothermia reduces oxygen requirements and protects kidneys. 32 Dutch Echocardiographic Cardiac Risk Evaluation Trial Outcomes 1. 2. 3. All-cause Mortality No Significant Importance of and Myocardial Difference in Accurate Risk Infarction Rates Outcomes Assessment Events before surgery: The study found no significant difference The trial emphasized the importance of Revascularization - 4.1% (mortality), 2.1% in outcomes between the two groups. accurate risk assessment. (MI) Similar perioperative and long-term Appropriate management strategies are No Revascularization - 6.1% (composite) morbidity and mortality despite crucial to optimize outcomes in patients Events up to 30 days after surgery: aggressive medical and surgical therapy. with vascular disease. Revascularization - 22.5% (mortality), 34.7% (MI), 42.9% (composite) 33 Anesthesia Considerations for Abdominal Aortic Reconstruction Choice of Anesthesia Radiation Safety Renal Protection Anesthesia choice (general, regional, or Importance of adhering to radiation safety Preventing contrast-induced nephropathy local) does not significantly impact principles (ALARA) to limit exposure during (CIN) is crucial in abdominal aortic perioperative outcomes in abdominal aortic endovascular procedures. reconstruction. reconstruction. Real-time radiation monitoring can help Strategies include limiting contrast load, Local or regional anesthesia may lead to adjust radiation dose accordingly. adequate hydration, and monitoring serum shorter hospital stays and procedure times creatinine levels post-procedure. compared to general anesthesia. Vascular Access and Blood Loss Surgeons typically use axillary or left brachial access for certain procedures in abdominal aortic reconstruction. Managing blood loss during endovascular repairs is essential to prevent coagulopathy and ensure optimal outcomes. 34 Mortality Rates in Open AAA Repair Mortality Rates in Open Surgical Repair of TAA Mortality rates vary from 5% to 14% in large institutions. Statewide and nationwide rates may be around 20%. Statewide Series Data 19% mortality at 30 days for elective TAA repair. 31% mortality at 365 days for elective TAA repair. Postoperative Complications Paraplegia or paraparesis in 3.8% to 40% of patients. Renal failure in 3% to 30% of patients. 6% of patients need postoperative dialysis, with 30% to 60% mortality. 35 Mortality Rates in Open AAA Repair Common Postoperative Issues Gastrointestinal, pulmonary, and cardiac complications. Pulmonary complications are the most frequent. Importance of Preoperative and Perioperative Management Accurate preoperative evaluation is crucial. Meticulous perioperative management is essential. Regionalization of Patient Care in Vascular Surgery Coordinated Care in Preoperative Planning for Risks and Complications Vascular Surgery TAA Repair of TAA Repair Involves collaboration among surgeons, Extensive evaluation and planning are Mortality rates range from 5% to 14%. anesthesiologists, and cardiologists. essential. Common complications include neurologic Aims to optimize patient outcomes. Includes assessing coexisting diseases and deficits, renal failure, and cardiac planning for blood loss management. complications. Anesthesia and Radiation Renal Protection and Safety in Endovascular Vascular Access in Procedures Endovascular Repairs Choice of anesthesia does not significantly Strategies focus on limiting contrast load and impact outcomes. ensuring hydration. Radiation safety follows the ALARA principle Surgeons often use axillary or left brachial to limit exposure. access for certain procedures. 37 Aortoiliac Occlusive Disease Interventions Operative Interventions Aortorenal bypass Extra-anatomic bypass Transaortic endarterectomy Suprarenal Clamping Open interventions often require suprarenal or supraceliac aortic cross-clamping Impacts cardiovascular and organ perfusion Endovascular Options Percutaneous transluminal angioplasty (PTA) with stenting is a primary treatment for selected patients 38 Aortoiliac Occlusive Disease Interventions Symptomatic Patients Operative repair is reserved for symptomatic cases Procedures like endarterectomy and bypass grafts often require supraceliac aortic cross-clamping Mortality Rates and Prevention of Complications Mortality rates for these procedures range from 7% to 18% Emphasizes the need for careful patient selection and management strategies Timely diagnosis and intervention are crucial to prevent severe consequences like bowel infarction and paraplegia Systemic Consequences of Aortic Cross-Clamping Metabolic Effects Hemodynamic Changes Renal Implications Aortic cross-clamping during vascular Arterial pressure, blood flow, and oxygen Renal blood flow is reduced during aortic surgery leads to significant systemic consumption below the clamp decrease by cross-clamping, emphasizing the importance consequences. 78% to 88%, 79% to 88%, and 62%, of maintaining renal perfusion. 50% decrease in total-body oxygen respectively. Optimal renal protection strategies include consumption with a reduction in tissues Infrarenal aortic cross-clamping increases hypothermia, mannitol administration, and above the clamp. arterial pressure (7% to 10%) and systemic prevention of hypotension and hypoperfusion Mixed venous oxygen saturation increases vascular resistance (20% to 32%), with a of the kidneys. above the celiac axis due to reduced oxygen decrease in cardiac output by 9% to 33%. consumption. 40 Hemodynamic Response to Aortic Cross-Clamping Hemodynamic Changes Due to Aortic Cross-Clamping Aortic cross-clamping during vascular surgery leads to significant hemodynamic changes. The level of the cross-clamp determines the systemic cardiovascular consequences. Arterial Responses to Cross-Clamping Arterial hypertension above the clamp and arterial hypotension below the clamp are consistent responses to aortic cross-clamping. The increase in arterial blood pressure above the clamp is primarily due to the sudden increase in impedance to aortic blood flow. Factors Influencing Hemodynamic Response Factors such as myocardial contractility, preload, blood volume, and sympathetic nervous system activation also play a role in the hemodynamic response. Clamping at different levels (infrarenal, suprarenal, supraceliac) impacts the cardiovascular system and vital organ perfusion differently. 41 Hemodynamic Response to Aortic Cross-Clamping Ischemic Complications and Monitoring Ischemic complications may result in renal failure, hepatic ischemia, bowel infarction, and paraplegia. Monitoring arterial blood pressure above and below the clamp is crucial for assessing perfusion to vital organs during aortic surgery. Anesthetic Technique and Hemodynamic Management Hemodynamic and metabolic changes associated with aortic cross-clamping are complex and dynamic, varying among experimental and clinical studies. The choice of anesthetic technique and management of hemodynamics play a critical role in the overall outcome of aortic surgery. Effects of Thoracic and Supraceliac Cross-Clamping Decrease in Total-Body Increased Mixed Venous Changes in Oxygen Consumption Oxygen Saturation Hemodynamics Below Thoracic aortic cross-clamping leads to a Aortic cross-clamping above the celiac axis Thoracic Aortic Cross- significant decrease in total-body oxygen results in increased mixed venous oxygen Clamp consumption by approximately 50%. saturation due to reduced oxygen Arterial blood pressure, blood flow, and consumption exceeding the reduction in cardiac output. oxygen consumption below a thoracic aortic cross-clamp decrease by 78% to 88%, 79% to 88%, and 62%, respectively, from baseline values. Effects of Supraceliac Perfusion Pressure and Cross-Clamping Blood Flow Supraceliac cross-clamping during aortic Blood flow through tissues and organs below surgery can lead to a significant increase in the level of aortic occlusion is dependent on systemic vascular resistance (20% to 32%) perfusion pressure and is independent of and a decrease in cardiac output (9% to cardiac output, emphasizing the importance 33%). of maintaining stable hemodynamics during aortic cross-clamping. 43 Morbidity and Mortality in Acute Renal Failure after Aortic Surgery 1. 2. 3. 4. Morbidity and Predictors and Renal Coagulopathy Mortality Causes Protection Management Acute renal failure after Postoperative renal Strategies Coagulopathy is a common aortic surgery is associated dysfunction is a strong complication during aortic with significant morbidity predictor of postoperative Strategies for renal surgery, with dilutional and mortality rates. renal failure. protection during aortic coagulopathy occurring The mortality rate with Renal failure can result from surgery include retrograde during massive transfusion. elective aortic surgery can preexisting renal distal aortic perfusion, Monitoring of coagulation be as high as 19% at 30 dysfunction, ischemia hypothermia, mannitol factors, platelet count, and days and 31% at 365 days. during cross-clamping, and administration, and fibrinogen levels is crucial Approximately 6% of hypovolemia. prevention of hypotension during aortic surgery to patients may require The primary predictor of and hypoperfusion. manage coagulopathy postoperative dialysis after postoperative renal failure is Pharmacologic agents like effectively. aortic surgery, with preoperative renal dopamine may be used to mortality rates ranging from dysfunction. dilate renal blood vessels 30% to 60%. and increase renal blood flow. 44 Hemodynamic and Metabolic Effects of Aortic Clamping Aortic Cross-Clamping Hemodynamic Response Metabolic Changes Effects Arterial hypertension above the clamp and Increased mixed venous oxygen saturation Aortic cross-clamping leads to a decrease in arterial hypotension below the clamp are occurs with aortic cross-clamping above the total-body oxygen consumption by consistent responses to aortic cross- celiac axis. approximately 50%. clamping. Reduction in oxygen consumption exceeding Tissues above the clamp experience a The systemic cardiovascular consequences the reduction in cardiac output leads to a decrease in oxygen consumption. can be dramatic, especially depending on decrease in total body oxygen extraction. Arterial blood pressure, blood flow, and the level of the cross-clamp application. oxygen consumption below the clamp decrease significantly from baseline values. Importance of Vital Organ Factors Influencing Protection Outcomes Vital organ protection during aortic cross- The level of aortic occlusion, status of the left clamping is crucial to prevent complications ventricle, and intravascular blood volume like renal failure, hepatic ischemia, and and distribution play significant roles in the coagulopathy. hemodynamic and metabolic changes during Ischemic complications may result in adverse aortic cross-clamping. outcomes such as renal failure, hepatic Proper maintenance of stable perioperative ischemia, bowel infarction, and paraplegia. hemodynamics is vital for overall outcome in aortic surgery. 45 General vs. Epidural Anesthesia in Aortic Surgery Controversy in Anesthetic Epidural Morphine Perioperative Myocardial Choice Benefits Ischemia The choice between general and epidural In a randomized trial using epidural The effects of anesthetic or analgesic anesthesia in aortic surgery remains morphine, a reduction in adrenergic response techniques on perioperative myocardial controversial. and less frequent hypertension in the ischemia have been extensively studied. Studies have not definitively shown whether postoperative period were noted. No consistent reduction in incidence the benefits observed are due to However, large randomized trials have not demonstrated with epidural techniques. intraoperative anesthetic techniques or demonstrated a reduction in nonsurgical postoperative analgesic regimens. complications with intrathecal opioids. Postoperative Challenges with Epidural Complications and Anesthesia Hospital Stay Challenges with epidural local anesthetics Postoperative complications, including during aortic reconstruction include cardiovascular, pulmonary, and renal issues, hypotension at aortic unclamping and have not shown significant differences based increased fluid and vasopressor on the use of epidural techniques. requirements. Length of hospital stay, a key outcome Some clinicians avoid running local variable, has not been consistently reduced anesthetics in the epidural around aortic with regional techniques in aortic surgery. clamping to manage these challenges effectively. Epidural opioids without local anesthetics can be used during aortic clamping, with local anesthetic administration post-aortic 46 unclamping once hemodynamics stabilize. Open Repair of the Thoracoabdominal Aorta 1. 2. 3. High-Risk Procedure Postoperative Management Open repair of the thoracoabdominal aorta Complications Strategies is associated with significant morbidity and mortality rates. Paraplegia or paraparesis can occur in Achieving normothermia and addressing 3.8% to 40% of patients. hyperkalemia are crucial. Renal failure occurs in 3% to 30% of Proper preoperative evaluation and patients, with 6% needing postoperative monitoring of coagulation factors, renal dialysis. function, and pulmonary status are Coagulopathy is frequent, requiring early essential. use of fresh frozen plasma and platelets. 47 Classification and Management of Aortic Aneurysms Classification of Aortic Management Strategies Importance of Collateral Aneurysms Surgical repair options include open surgical Blood Supply Aortic aneurysms are classified based on repair and endovascular repair using stent- Collateral blood supply plays a vital role in their location and extent, such as thoracic, grafts. maintaining spinal cord integrity during Endovascular approaches, like fenestrated abdominal, or thoracoabdominal. aortic aneurysm repair. Specific classifications include descending stent-grafts (FEVAR) and multi-branched Sufficient collateral blood flow is essential to thoracic aortic aneurysms, abdominal aortic grafts (mBEVAR), are utilized for complex prevent spinal cord ischemia and related aneurysms, and complex thoracoabdominal abdominal aortic aneurysms. complications post-surgery. Careful patient selection is crucial for aortic aneurysms. determining the most suitable management Predictors of Delayed Renal approach.Ischemia and Neurologic Deficits Protection Preoperative renal dysfunction, acute Renal failure post-aortic surgery can result dissection, and specific types of aortic from various factors, including preexisting aneurysms are significant predictors of renal dysfunction, ischemia during cross- delayed neurologic deficits post- clamping, and hypovolemia. thoracoabdominal aortic aneurysm repair. Strategies for renal protection include Postoperative hypotension and cerebrospinal retrograde distal aortic perfusion, fluid (CSF) drainage issues can contribute to hypothermia, and pharmacologic agents like the development of neurologic deficits. mannitol and dopamine. 48 Monitoring Techniques in Thoracic Aortic Aneurysm Repair 1. 2. 3. 4. 5. Utilization Importanc Considerat Continuou Post- of e of ion of s Operative Transesop Transcrani Spinal Hemodyna Pain hageal al Motor Cord Blood mic Control Echocardi Evoked Supply Monitoring Maintain stable hemodynamics ography Potential Blood supply from Monitor for Improve patient posterior spinal hemodynamic (TEE) (MEP) arteries stability outcomes Intraoperative Monitoring Blood supply from anterior spinal Early identification of blood loss assessment of arteries Ensure optimal global ventricular Assess spinal cord Maintain spinal cord perfusion to key function function Prevent paraplegia integrity organs Monitoring for myocardial during surgery ischemia 49 Anesthetic Management of Aortic Surgery Importance of Anesthetic Spinal Cord Protection Renal Ischemia and Technique Emphasize the significance of collateral Protection Utilize balanced anesthesia with an opioid, blood supply for spinal cord integrity during Address the risk factors for renal failure after low-dose volatile anesthetic, benzodiazepine, aortic surgery. aortic surgery, including preexisting renal Prevent delayed neurologic deficits post- and muscle relaxant for aortic surgery. dysfunction, ischemia during cross-clamping, Ensure controlled induction, avoid repair. and hypovolemia. hypertension, and maintain baseline heart Discuss strategies such as retrograde distal rate to prevent myocardial ischemia. aortic perfusion and pharmacologic agents like mannitol and dopamine for renal protection. Coagulation Management Highlight the common occurrence of coagulopathy during aortic surgery. Focus on the importance of monitoring coagulation factors during massive transfusion to prevent dilutional coagulopathy. Discuss the need for early use of fresh frozen plasma and platelets to avoid severe coagulopathy. 50 Anesthetic Technique for Thoracic Aortic Aneurysm Repair Balanced Anesthesia Combines an opioid, low-dose volatile anesthetic, benzodiazepine, and muscle relaxant. Induction of General Anesthesia Slow and controlled to avoid complications like hypertension and myocardial ischemia. Spinal Cord Ischemia Significant concern during surgery. Optimal arterial blood pressure and cerebrospinal fluid drainage are crucial to prevent neurologic deficits. 51 Anesthetic Technique for Thoracic Aortic Aneurysm Repair Blood Supply to Spinal Cord Predominantly from the anterior spinal artery. Protection of this artery is vital during surgery. Postoperative Analgesic Regimen Focus on pain control. Maintain stable hemodynamics for optimal recovery Cerebrospinal Fluid Drainage in TAA Repair Importance of CSF Benefits and Strategies Management and Drainage in TAA Repair CSF drainage helps maintain spinal cord Monitoring CSF drainage is crucial for optimizing spinal integrity in high-risk patients undergoing TAA Careful management of CSF drainage is cord perfusion during thoracoabdominal repair (class I, level of evidence B). essential to avoid complications such as Strategies include monitoring CSF pressure aortic aneurysm (TAA) repair. intracranial hypotension and hemorrhage. Guidelines recommend CSF drainage for and periodic drainage to prevent SCI. CSF pressure is typically maintained between high-risk patients undergoing aortic 10 to 15 mmHg during TAA repair procedures to prevent spinal cord injury procedures. (SCI). Precautions Role in Outcomes Avoid excessive rapid CSF drainage, CSF drainage reduces the risk of SCI and especially during heparinization or ensures optimal outcomes in TAA repair postoperative coagulopathy, to prevent procedures. complications. Spinal drains may be placed preinduction or postinduction based on patient tolerance and procedural requirements. 53 Preoperative Localization of the Adamkiewicz Artery 1. Preoperative Localization of the Adamkiewicz Artery The Adamkiewicz artery is a critical vessel supplying the anterior spinal cord. It is essential to identify the Adamkiewicz artery preoperatively to prevent spinal cord ischemia. Localization techniques involve angiography and imaging to map the artery's course. The Adamkiewicz artery typically arises from the left intercostal or lumbar arteries. Accurate identification is crucial for minimizing the risk of spinal cord injury during vascular procedures. 54 Coagulopathy and Metabolic Issues in TAA Repair Coagulopathy in TAA Metabolic Management in Repair TAA Repair Dilutional coagulopathy can occur during Achieving normothermia is essential for massive transfusion, leading to platelet patient safety during and after surgery. deficiency and decreased coagulation Addressing hyperkalemia is crucial, factors. especially in patients with oliguric or anuric Monitoring of prothrombin time, partial conditions. thromboplastin time, fibrinogen level, and Use of calcium chloride, sodium bicarbonate, platelet count is crucial. insulin, and glucose for acute treatment of Cryoprecipitate may be necessary to correct hyperkalemia. coagulopathy, especially when clotting Intraoperative cell salvage may be factors are diluted to critical levels. considered to reduce allogeneic blood Antifibrinolytic therapy like å-aminocaproic transfusions, particularly in cases of acid or tranexamic acid can be beneficial if expected significant blood loss. coagulopathy persists. 55 Use of Stent-Grafts in Vascular Surgery 1. 2. 3. 4. 5. Stent- Fenestrate Multi- Off-the- Benefits of Graft d Stent- Branched Shelf Endovascu Devices Grafts Grafts Stent- lar FDA-approved for (FEVAR) (mBEVAR) Grafts Approache various aortic diseases such as Specifically Utilized for treating Ready-to-go types s traumatic designed for complex abdominal used for complex correcting aortic aneurysms, abdominal aortic Over open repairs, transections, ruptures, pararenal and providing routes to aneurysms, including shorter penetrating ulcers, juxtarenal aortic cannulate and stent showing promising hospital stays, dissections, and aneurysms through target mesenteric results in reducing procedure times, aneurysms. endovascular or renal vessels. perioperative and reduced blood mechanisms. complications. loss. 56 Spinal Cord Blood Supply in Anesthesia Management Blood Supply to the Optimizing Spinal Cord Guidelines for High-Risk Spinal Cord Perfusion Patients The spinal cord receives its blood supply Arterial pressure augmentation CSF drainage is recommended for high-risk from two posterior arteries (approximately Cerebrospinal fluid (CSF) drainage patients undergoing aortic procedures to 25%) and one anterior spinal artery Lowering central venous pressure (CVP) prevent spinal cord injury (SCI). (approximately 75%). Careful monitoring and management of CSF drainage are crucial to avoid complications such as intracranial hypotension and hemorrhage. Measures to Decrease SCI Perioperative Risk Management Maintain flow through the left subclavian Arrange perioperative management of artery and internal iliac arteries. anticoagulant or antiplatelet therapy with Spinal drains may be placed preinduction of the perioperative team. general anesthesia or postinduction if the Excessive rapid CSF drainage, particularly patient cannot tolerate the procedure. during heparinization or postoperative coagulopathy, could lead to intracranial hypotension and increase the risk of intracranial hemorrhage. Discussion with the surgeon and patient should occur if bloody CSF is encountered during placement, potentially leading to rescheduling of the procedure. 57 Routine fluoroscopic-guided spinal drain Anesthesia Considerations for EVAR Importance of Hemodynamic Stability Ensuring stable blood pressure and perfusion to key organs during stent deployment. Use of Rapid Ventricular Pacing (RVP) Employed to induce hypotension during deployment, preventing stent migration. Antifibrinolytic Therapy Considered in cases of persistent coagulopathy during EVAR procedures. Deflectable Guiding Sheaths Facilitating cannulation of caudally oriented vessels from femoral access sites. 58 Preventing Spinal Cord Injury in Vascular Surgery Importance of Collateral Risk Factors for Spinal Strategies for Spinal Cord Blood Supply Cord Injury Protection Ensure sufficient collateral blood supply Emergency surgery Utilize arterial pressure augmentation independent of the Adamkiewicz artery to Aortic dissection Cerebrospinal fluid (CSF) drainage maintain spinal cord integrity during vascular Extensive aortic disease Maintain adequate perfusion to optimize surgery. Aortic rupture spinal cord function Prior abdominal surgery Role of CSF Drainage Monitoring and Consider CSF drainage for high-risk patients Management undergoing aortic procedures to prevent Monitor CSF pressure spinal cord injury (Class I, level of evidence Drain periodically B). Avoid over-draining to prevent complications like intracranial hypotension and hemorrhage. 59 Management of Endoleaks in Aortic Procedures Understanding Endoleaks Endoleaks are a common complication in aortic procedures. Types I and II require immediate treatment due to the risk of aneurysm sac pressurization. Innovative Solutions Fenestrated stent-grafts (FEVAR) and multi-branched grafts (mBEVAR) show promise in correcting pararenal and juxtarenal aortic aneurysms. These solutions utilize endovascular mechanisms. Off-the-Shelf Stent-Grafts Used for complex abdominal aortic aneurysms. Benefits include no perioperative deaths, ruptures, aneurysm dilation, or 60 stent migration. Management of Endoleaks in Aortic Procedures Effective Management Strategies Careful patient selection is crucial. Consideration of adjunctive retroperitoneal procedures is important. Anesthesia Planning Tailored to the surgical approach and vascular access. Essential for successful endoleak management in aortic procedures. Anesthetic Management of Hybrid Arch Repairs 1. 2. 3. 4. Precise Stent Rapid Increasing Complexities Deployment Ventricular Frequency of of Hybrid Arch Anesthetic management of Pacing (RVP) Hybrid Repair TEVAR must ensure precise deployment of stents at RVP is preferred for Procedures Understanding the short proximal landing profound hypotension complexities of hybrid arch during deployment, offering Hybrid aortic arch repair repair types I, II, and III is zones near the arch vessels. Deployment challenges due precise control over onset procedures are increasing in crucial for successful to aortic blood flow and duration compared to frequency, requiring precise outcomes in aortic arch dynamics necessitate pharmacologic methods. stent deployment near arch pathology management. techniques like rapid vessels to prevent ventricular pacing (RVP) to complications like limit stent migration. endoleaks. 62 Aortic Arch Pathology in TEVAR with RVP Aortic Arch Pathology in Role of Rapid Ventricular Visual Representation TEVAR Pacing (RVP) A schematic illustration of aortic arch Aortic arch pathology in TEVAR often requires The use of rapid ventricular pacing (RVP) pathology in TEVAR with RVP can provide a a concurrent or staged open debranching during TEVAR is crucial for inducing visual representation of the complex procedure, such as carotid-carotid or carotid- hypotension to limit stent migration, procedures involved in managing aortic arch subclavian bypass, to allow stent particularly when the planned stent graft is diseases with stent deployment techniques. deployment across the origins of the arch in close proximity to the left ventricular vessels while maintaining perfusion to the outflow tract. head and upper extremities. RVP is preferred for its ability to produce Debranching procedures are essential for profound hypotension quickly and with facilitating stent deployment near the arch shorter duration compared to other drugs, vessels during TEVAR, ensuring precise aiding in the precise deployment of stents in deployment and preventing complications challenging aortic arch repairs. like stent migration. 63 Management of Endoleaks in Aortic Procedures 1. 2. 3. 4. 5. Identificati Types of Importanc Managem Postopera on and Endoleaks e of ent tive Classificati Type I: Proximal or Detection Strategies Surveillan distal attachment on site leak. Early identification Treatment options ce Type II: Branch of endoleaks is include Endoleaks are a crucial to prevent observation, Regular imaging vessel or lumbar common artery perfusion. aneurysm embolization, studies, such as CT complication in Type III: Graft expansion and revision of the angiography, are aortic procedures. junctional leak. potential rupture. stent-graft, or essential for Characterized by Type IV: Graft Emphasizes the conversion to open monitoring persistent blood porosity. need for vigilant repair. endoleaks post- flow within the postoperative Choice of treatment procedure. aneurysm sac after monitoring. depends on the Ensures timely stent-graft type and severity of intervention if placement. the endoleak. needed. 64 Anesthetic Management of Hybrid Arch Repairs Precise Deployment of Rapid Ventricular Pacing Balancing Hemodynamic Stents (RVP) Stability Anesthetic management of TEVAR must RVP is preferred for inducing hypotension Anesthetic techniques for hybrid arch repairs ensure precise deployment of stents at short during stent deployment, as it offers more involve a careful balance to maintain proximal landing zones near the arch vessels rapid and profound hypotension compared to hemodynamic stability and prevent to prevent complications like stent migration. other methods. complications during the procedure. Deployment during TEVAR can be complex The choice of anesthetic technique should be due to aortic blood flow dynamics, based on factors like aneurysm complexity, necessitating techniques like rapid patient's condition, and the experience of the ventricular pacing (RVP) for precise surgical and anesthesia teams. Challenges deployment. and Considerations The importance of understanding the specific challenges and considerations in anesthetic management for hybrid arch repairs to ensure successful outcomes. Anesthetic management plays a crucial role in the success of hybrid aortic arch repair procedures, emphasizing the need for a comprehensive and tailored approach for each patient. 65 Aortic Arch Pathology in TEVAR with RVP Concurrent or Staged Open Debranching Procedures Aortic arch pathology in TEVAR often requires a concurrent or staged open debranching procedure, such as carotid-carotid or carotid-subclavian bypass. This allows stent deployment across the origins of the arch vessels while maintaining perfusion to the head and upper extremities. Importance of Debranching Procedures Debranching procedures are essential for precise stent deployment near the arch vessels during TEVAR. They help prevent complications like stent migration. 66 Case Study: Type 1A Endoleak This reflects advancements in Fig. 56.17: Computed tomography endovascular technology and the need for precise stent graft scan showing a progressively enlarging type 1A endoleak post- placement. endovascular aneurysm repair. Role of Rapid Ventricular Pacing This emphasizes the importance of (RVP) proper management in such cases. The use of rapid ventricular pacing (RVP) during TEVAR facilitates Hybrid Approaches and Advancements precise stent deployment at short proximal landing zones near the Hybrid approaches for aortic arch arch vessels. aneurysmal pathology are This prevents complications like the increasingly performed. windsock effect. Management of Spinal Cord Injury in Vascular Surgery Spinal Cord Injury Risk Strategies for Spinal Cord Complications and Factors Protection Prevention Occlusion risk of stent grafts associated with Arterial pressure augmentation, Early complications: postimplantation the AKA cerebrospinal fluid (CSF) drainage, and syndrome, paraplegia, stroke, acute renal Damage to middle sacral arteries, inferior lowering central venous pressure failure mesenteric arteries, or internal iliac arteries CSF drainage recommended for high-risk Late complications: endoleaks, aneurysm Risk factors include emergency surgery, patients undergoing aortic procedures rupture, graft infection aortic dissection, extensive aortic disease, Importance of maintaining collateral blood Early detection and intervention crucial for and prior abdominal surgery supply for spinal cord integrity complications like paraplegia and stroke Measures to Decrease Importance of Optimal Risk Renal Protection Maintain flow through left subclavian artery Use of hypothermia, mannitol, and and internal iliac arteries prevention of hypotension and hypoperfusion Careful monitoring and management of CSF for renal protection drainage to avoid complications Pharmacologic agents like dopamine for Avoid over-draining CSF to prevent renal protection during ischemia intracranial hypotension and hemorrhage Considerations for minimizing nephrotoxic effects of angiographic dyes and risk of renal ischemia during aortic cross-clamping 68 Endoleak Management and Postimplantation Syndrome Types of Endoleaks Type II Endoleak: Reverse filling from branch vessels, treated with transarterial or translumbar embolization. Type III Endoleak: Structural failure of stent-graft, requires immediate intervention with new stent graft insertion. Type IV and V Endoleaks: Associated with graft porosity and sac enlargement, respectively. Treatment Options for Endoleaks Embolization through iliac or mesenteric arteries. Surgical interventions range from ligation of feeding arteries to graft excision and open repair. Postimplantation Syndrome (PIS) 69 Endoleak Management and Postimplantation Syndrome Occurs after endovascular aortic procedures, characterized by fever, leukocytosis, and coagulopathy. Treatment involves supportive care with antipyretics and transfusions as needed. Hybrid Arch Repairs Incorporate TEVAR with conventional repair for aortic arch pathologies. Types I, II, and III hybrid repairs are utilized for complex cases. Enhances aortic arch reconstruction in high-risk patients with comorbidities. Importance of Preoperative Planning Collaboration between anesthesia and surgical teams crucial for managing potential complications. 70 Summary The management of the vascular surgery patient is a complex process. Most of these patients present with co-morbidities Anesthesia must be tailored to the patient and surgical needs Hemodynamic stability is paramount Renal, cerebral, and spinal cord protection must be maintained to avoid post-operative complications References Miller’s Anesthesia 9th ed chapter 56