ANESTHESIA For VASCULAR SURGERY

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ANESTHESIA For VASCULAR SURGERY

• Mark Welliver MS, CRNA

Significant contributions from original by Gwenn
Randal MSN, CRNA
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Outline

• Introduction
• Carotid endarterectomy (not covered)
• Peripheral vascular surgery
• Bypass grafting
• Embolectomy
• Abdominal aortic surgery
• Endovascular Surgery
• Thoracic aortic surgery

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Vascular Surgery Patients

• Coexisting diseases
• CAD 40-80
• Htn
• Diabetes
• Smokers
• CNS carotid disease, stroke
• Renal
• 50 of post op mortalities d/t MI
• If the surgical site is sclerotic so are other
  areas

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Carotid Vascular surgery

• Consider carotid vascular disease coexisting
• CEA Covered next spring in trauma course

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Peripheral Vascular Surgery

• Bypass grafting for occlusive disease or
  aneurysms
• Upper or lower extremities
• Endogenous vessels or synthetic (Gortex)
• Anesthesia options
• General
• Regional

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Peripheral Bypass

• Potential for blood loss type and cross 2U
• 2 large bore IV access (18 minimal)
• Consider central line fluids and CVP (PA?)
• Fluid warmers with blood tubing
• Colloids available Hespan, albumin
• A-line for unstable or ASA 3,4
• Heating blankets (burn risk)
• Serial HH, Abgs

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Peripheral Bypass

• Femoral-popliteal and lower
• general, spinal, epidural
• Ileo-femoral and lower
• general, spinal, epidural
• Axillo-femoral
• General, regional, local

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Peripheral Embolectomy

• Potential for significant blood loss
• Type and screen minimal
• Large bore IV access
• Often MAC with local
• Duration?

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Abdominal Aortic Surgery

• Aorta below diaphragm
• Bypass grafting for occlusive disease or
  aneurysms
• Over sew or synthetic grafts (Gortex)
• Anesthesia option General alone or with epidural
  catheter adjunct

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Abdominal Aortic Aneurysm

• Common in older adults gt60 (5-7)
• Appears to be a genetic link because this type of
  aneurysm tends to run in families.
• Usually occurs in people with atherosclerosis.
• Symptoms abdominal, groin, back pain, syncope,
  flank mass, or paralysis
• Diagnosis routine physical find, abdominal
  ultrasound.

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Abdominal Aortic Aneurysm

• Society of Vascular Surgery and the International
  Society for Cardiovascular Surgery have
  characterized abdominal aneurysms as
• -suprarenal
• -juxtarenal
• -pararenal
• -infrarenal
• 90-95 of AAAs involve the infrarenal abdominal
  aorta.

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Aneurysms
True aneurysm Involves dilation of all 3 layers
of the vessel wall (outer) Tunica externa-
fibrous connective tissue (middle) Tunica Media-
smooth muscle/elastic tissue (inner) Tunica
interna- epithelial layer, squamous cells False
aneurysm Caused by disruption of 1 or more layers
of the vessel wall.
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Abdominal Aortic Aneurysm

• lt4cm--- u/s q 6 months
• 4-5cm elective repair w/low operative risk and
  good life expectancy.
• 5-6 cm need repair (mortality rate 0.9-5)
• 6-7 cm threshold for rupture (mortality as high
  as 75).

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Overview

• Large incision in the abdominal wall, just below
  your breastbone to top of the pubic bone
• Aorta clamped
• Aneurysm cut open
• Plaque and clotted blood removed
• Aortic graft sewn in place- functions as a
  conduit for blood flow

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Management

• Potential for blood loss type and cross 2U
• large bore IV access (18 minimal)
• Central line fluids and CVP (PA?)
• Fluid warmers with blood tubing
• Colloids available Hespan, albumin
• A-line
• Vasodilator gtts and vasopressors
• Clamping issues
• Heating blankets (burn risk)
• Serial HH, ABGs

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Endosvascular Surgery

• Performed under local, mac, ga, regional
• Radial a-line IVs in right arm
• Left arm both groins used for surgical access
• Patients are discharged in 1-2 days post-op
• Approved September 2000 by FDA.
• Disadvantages
• Endoleaks- (failure to exclude the AAA)
• Require follow-up evals w/serial CT scans
• Demands more office visits than open

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Endovascular grafting (EVR)

• Catheter tip inserted through a groin artery into
  abdominal aorta using fluoroscopy
• Catheters tip holds a deflated balloon.
• Balloon inflated, graft opens to span the length
  and width of the artery.
• Devices at both ends of the graft secure it to
  the inner wall of aorta to strengthen it and keep
  from rupturing
• May not be available at all hospital facilities.
• ADV much less invasive

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Endovascular Stent Grafts Indications

• Severe COPD
• Severe cardiac disease
• Active infection
• Medical problems that preclude operative
  intervention.
• 1.5cm neck of aorta to pass graft between the
  renal arteries and the aneurysm
• Anatomy/ braches/graft selection factors

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Thoracic Aortic Surgery

• Aneurysms
• Dissection
• Occlusive disease
• Trauma (covered in neuro/trauma)
• Coarctation (covered in Pediatrics)

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Risks

• Most often requires CPB
• Large blood losses
• Hypertension pre-op, hypotension intra-op
• Myocardial ischemia
• Renal ischemia
• Spinal ischemia
• Death

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Aneurysms

• Rupture-death 1 risk. gt6cm 50 rupture w/in one
  year.
• Surgical repair 2-5 mortality risk
• Leaking gt50 mortality
• Thoracic aneurysms tracheal /or bronchial
  compression/deviation, Laryngeal nerve
  compression

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Thoracic Aneurysm

• Ascending-between aortic valve innominate
• Arch- between innominate l. subclavian
• Descending- distal to l. subclavian

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Classification of thoracic aneurysms

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Anesthetic Management

• Ascending Aorta
• Similar to cardiac surgery utilizing CPB
• Consider fem-fem bypass(risk rupture w/sternotomy
• Special considerations
• Long aortic cross clamp times
• Large blood loss
• Right radial A-line (why?)

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Anesthetic Management

• Aortic Arch
• Similar to cardiac surgery utilizing CPB median
  sternotomy
• Goal- cerebral protection
• Hypothermia
• Thiopental infusion
• Maintain flat EEG
• Corticosteroids
• Free radical scavengers

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Anesthetic Management

• Descending Aorta
• Usually without CPB
• L. thoracotomy incision
• One lung anesthesia
• PA cath, A-line, Many large bore ivs, TEE, Cell
  saver, SSEP
• Cross Clamping issues
• ?SVR, myocardial ischemia, CHF, ?CO,
• Limit fluids pre-clamping
• ?anesthetic depth
• Ntg, nitroprusside gtts primed ready
• Clamp Release issues
• SEVERE HYPOTENSION,?SVR
• Preload w/fluids(crystaloid,colloid) before
  release, vasodilators OFF
• ABGs acidosis (bicarb, ?min. vent.)
• Paraplegia risk d/t thoracolumbar artery injury
• Renal failure

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Aortic Occlusive Disease

• Incorporates Aortobifem grafting with/without
  peripheral thromboendarterectomy
• Tx same as above with focus on location
• Rarely a localized phenomena