Endovascular Abdominal Aortic Aneurysm Repair (EVAR)

Airway: Access: Pain: Position: Time: Blood loss: Special:

Endovascular repair of aorta using percutaneously inserted grafts. EVAR:

• Preferred approach in most patients provided the anatomy is favourable, as:
  • No laparotomy
  • No cross-clamp
  • Reduced perioperative morbidity and mortality
• May be:
  • Standard EVAR
  • Thoracic EVAR
  • Fenestrated EVAR
• Involves access via:
  • Femoral arteries
    Standard EVAR.
    • Supine
    • May limit distal flow
  • Subclavian arteries
    Required for complex grafting.

Considerations

• B
  • Requirement for breath-holding
    Major effect on anaesthetic plan; either:
    • GA & ETT
    • Light sedation and obeying commands
      
      • May be difficult to maintain patient comfort in long procedures
      • Requires ability to lie flat
• C
  • Conversion to open
    Incredibly rare.
• D
  • Anaesthetic technique
    • Local
    • Neuraxial
    • GA with ETT

Preparation

Induction

Intraoperative

Surgical Stages

Emergence

Postoperative

Complications include:

• C
  • Post-implantation syndrome
    Early, self-limiting, postoperative occurrence of:
    • Fever
    • Leukocytosis
    • Raised inflammatory markers
  • Endograft collapse
    Collapse of the endograft:
    • Usually occurs within 3 months
    • May present:
      • Asymptomatically
      • Abdominal pain
      • Multiorgan failure
      • Reduced femoral pulses
  • Endoleaks
    Leakage of blood into aneurysm sac around graft.
    • Occurs in ~30% of patients
    • Classified into:
      • Type I
        Incomplete seal. Requires repair.
      • Type II
        Leakage of blood from collateral vessels. Requires repair.
      • Type III
        Inadequate sealing of overlapping graft joints. Requires repair.
      • Type IV
        Direct leakage through a porous graft. Historical curiosity of old grafts.
  • Major bleeding
  • Abdominal compartment syndrome
    ~15% of cases, more common if blood loss >5L.
  • MACE
• D
  • Spinal cord ischaemia
    Related to spinal perforator injury. Management aimed at ↑ spinal perfusion pressure:
    • CSF drain to 10mmHg
    • ↑ MAP to 100mmHg or whatever resolves neurology
• F
  • AKI
• G
  • Mesenteric ischaemia

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References