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Repair of Ruptured Thoracic Aortic Aneurysm Performed Using Local Anesthesia

May 2015 - Aortic Care

Patients with a ruptured thoracic aortic aneurysm are often elderly and have substantial comorbidities that increase the risk of perioperative complications during open surgery with general anesthesia. Endovascular aortic repair (EVAR) offers a minimally invasive option, and it can be performed percutaneously without general anesthesia, reducing perioperative risk.1 The percutaneous strategy is only available at a small number of centers in the country, including University of Minnesota Health Aortic Center. In this case study, we describe an elderly patient with a large, ruptured thoracic aneurysm of the aorta who was at high risk for general anesthesia complications. Her aortic emergency was successfully managed with percutaneous endovascular aortic repair (pEVAR) under local anesthesia with light sedation.

Patient

An 84-year-old female presented to her local emergency department with chest pain. She was found to have a large, ruptured thoracic aortic aneurysm (Figure 1). The local physician contacted the University of Minnesota Health Aortic Center Emergency Triage Line, and within minutes a conference call was convened with 2 vascular surgeons, an emergency department physician, and a cardiovascular/thoracic surgeon from University of Minnesota Medical Center. After careful consultation with the referring physician, the decision was made to transfer the patient to the Aortic Center at University of Minnesota Medical Center for a complex stent graft placement.

Preop-MRI-aortic-aneurysm Consult-5-2015-443x292
— Figure 1. Preoperative MRI of a large, ruptured thoracic aortic aneurysm in an 84-year-old female

Management

The patient’s diagnosis was confirmed upon arrival and initial management was performed in the emergency department. Within 1 hour of the initial triage line call, she was taken to the hybrid operating theater. The surgical team consisted of a vascular surgeon, a cardiac surgeon, and an interventional radiologist. The patient was kept awake with light sedation and local anesthesia for the procedure, since her age and comorbidities put her at high risk of ventilator-acquired pneumonia. The groin vessels were accessed percutaneously with the assistance of ultrasound guidance. A series of guide wires were used to traverse the damaged aorta in the chest. Within minutes, the aneurysm and the tear were covered with a 2-component stent graft, which went from the left subclavian down to the celiac artery (Figure 2). The patient recovered well and is at home with her family.

Postop-MRI-stent-graft Consult-5-2015-443x292
— Figure 2. Postoperative CT scan showing the 2-component stent graft used in repair of the ruptured thoracic aortic aneurysm. The 2-component stent graft extends from the left subclavian artery to the celiac artery

Discussion

The use of local anesthesia for endovascular repair reduces operative risk in elderly patients with comorbidities. A recent meta-analysis of 10 studies comprising 13,459 aortic aneurysm repairs compared outcomes between patients receiving local anesthesia and those receiving general anesthesia.1 No differences in 30-day mortality rates were seen, despite the fact that the local-anesthesia patients were older and had an increased burden of cardiac and respiratory comorbidities than did the general anesthesia patients. In addition, the local-anesthesia group was found to have shorter operative times and hospital stays and fewer postoperative complications than did the general anesthesia group.

University of Minnesota Health Aortic Center is the only center in the state to have performed pEVAR of a thoracic aortic aneurysm using local anesthesia without intubation, and it is one of few centers in the United States routinely offering pEVAR with local anesthesia for emergent ruptures, as was the case for the patient described in this study.

References

1. Karthikesalingam A, Thrumurthy SG, Young EL, et al. Locoregional anesthesia for endovascular aneurysm repair. J Vasc Surg. 2012;56:510-519.

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