Aortic aneurysms and their anaesthetic management

Moderator : Dr. Ashwani Presenter: Dr. Monika

Largest vessel in the body

the aorta starts at the aortic valve and ends at the iliac bifucation. Asc. Arch, desc. Intima , media and adventitia

Aneurysma meaning a widening.

An aortic aneurysm refers to an abnormal, localized blood vessel wall weakness and bulging or ballooning(dilation) in a segment of the aorta, usually 50% over the normal diameter. Normal diameter of aorta: 3cm at the origin 2.5cm in desc. portion of thorax 1.8-2cm in the abdomen

TYPES:
True aneurysms: if contain all the three layers. False/pseudoaneurysm: if only the outer layer remains. Based on location: Acc. to shape: Fusiform (symmetrical) Saccular (asymmetrical)

Abdominal aortic aneurysms(AAA): 75%, infrarenal most common Thoracic aortic aneurysm: 25%, ( asc., arch, desc.) Thoracoabdominal aortic aneurysm (TAAA):

TAA
Diameter of the thoracic aorta 1.5 times greater than normal (or larger) Incidence 5.9 per 100,000 personyears Median age 65 years (2-4)M>F Desc. TAA> Asc.TAA> Aortic arch
TAA

CRAWFORD CLASSIFICATION OF TAAA

DEGENERATION & DISSECTION Atherosclerosis(80%) Chronic aortic dissection(17%) Marfans syndrome, Loeys Dietz syndrome Ehlers-danlos syndrome Familial thoracic aortic aneurysm syndrome Congential aortic aneurysms (Bicuspid aortic valve,
coarctation)
Traumatic aneurysms Annuloaortic ectasia: isolated

dilation of asc aorta, aortic root, Syphilitic (rare) aortic valve annulus Central AR Tuberculosis aneurysms Mycotic aneurysm Vasculitides : takayasus arteritis, giant cell arteritis Spondyloarthopathies: Bechets ds causes TAAA

Aortic dissection
Ascending (65%), arch (20%), descending thoracic (10%), abdominal (5%) Acute (2/3), chronic (1/3)

STANFORD CLASSIFICATION
Type A: involve ascending aorta Type B: dont involve ascending aorta

DEBAKEY CLASSIFICATION

CLINICAL FEATURES
Remain asymptomatic for long(silent killer) Chest or back pain Rupture of asc. Aortic Hoarseness Atelectasis Dysphagia Dyspnea Superior vena cava syndrome Wheezing, cough, hematemesis, hemoptysis Symptoms of AR Embolism with stroke,mesentric or limb ischemia
aneurysm in to pericardial sac causes cardiac temponade Desc. AA rupture causes hemothorax, aortobronchial fistula, aortoesophageal fistula

DIAGNOSIS
Abnormal chest x-ray Transthoracic ultrasound examination Aortic angiography & digital subtraction angiography (gold standard) CT, MRI: 87-100% CTA MRA TEE : 99-100% Abdominal USG

TREATMENT OPTIONS

Medical management/monitoring(watchful waiting)

Open surgery Endovascular repair

No proven lifestyle changes can decrease the size of TAAs.
TEVAR animation video

Medical management / monitoring

TAAs under 5cm BP lowering drugs Goal to maintain SBP between 105120mmhg Long term beta-blocker therapy . Statins Restriction of some physical activities. Serial surveillance by imaging studies 2nd imaging study obtained 6months after initial diagnosis

 Atherosclerotic aneurysm diameter

Ascending aorta Descending aorta > 5.5cm > 6.5cm

Marfans or familial thoracic aneurysm diameter Ascending aorta > 5.0cm Descending aorta > 6.0cm

Severe aortic regurgitation Aortoannular ectasia with dilated aortic root Congential bicuspid aortic valve Contained or impending rupture Symptoms refractory to medical management Increase in aneurysm diameter > 1cm/year

REPAIR OPTIONS

Endovascular surgery:
Requires single small incision in the groin area.
An endovascular graft is inserted through the femoral artery via a catheter and deployed inside the lumen, relining the aorta.

Average ICU stay: 2-3 days Average recovery time: 1-2 weeks

REPAIR OPTIONS

Open surgery:
Requires thoracotomy Aorta is cross-clamped above diseased aortic segment Affected segment is replaced with fabric surgical graft Average hospital stay: 2-3 weeks Average recovery time: 3 months Elective repair: up to 10% mortality Emergent repair: up to 50% mortality

1. Urgency of the surgery : emergent, urgent or elective 2. Pathology, anatomic extent of the lesion provide information about physiologic impact and consequences of the lesion, permitting anaesthesiologist to anticipate potential difficulties associated with anaesthetic procedures, problems related to surgical repair and postoperative complications. 3. Baseline functional reserve of each organ system : (often elderly and have CO-EXISTING DISEASES)

Preexisting or associated medical conditions

Heart:
>50% have severe CAD. 90% hypertensive Left ventricular systolic dysfunction 5 times more common Valvular dysfunction, arrhythmias, cardiomyopathy,Prior aortic surgery (increased risk of CHF, perioperative MI, death)

Pulmonary disease:
COPD, chronic bronchitis, smoking Increased risk of post-op pulmonary complications PFTs useful in evaluating &optimizing respiratory function Baseline hypercapnia(paCo2>45mmhg) increases the risk Bronchodilators may be indicated but risk of beta agonist induced arrhythmia or MI should be considered. Antibiotics ; short course of glucocorticoids

Renal insufficency:
Alters fluid management Serum creatinine level>2mg/dl creatinine clearance <60ml/min are independent risk factors for cardiac complications Avoid nephrotoxic drugs N-acetylcysteine or sodium bicarbonate to reduce risk of contrast related nephropathy

Liver &hematologic dysfunction

Cogulopathy Increased post-op bleeding

CNS:
Cerbrovascular disease BP management to ensure adequate cerebral perfusion

Atheroclerosis or peripheral vasular disease

Increased risk of stroke, limb ischemia

Esophageal or cervical disease: containdication to TEE

 4. Hemodynamic status, intravascular volume access and management 5. Airway patency:Aortic pathology distorting trachea/bronchus
may increase difficulty to tracheal and endobronchial intubation.

6.Pre-operative medications: Antihypertensives, beta-blockers, other cardiac medications, pulmonary, antiseizure medication continued till morning of surgery Discontinue oral hypoglycemics(metformin) Warfarin, Coumadin discontinued 3-7 days before Aspirin, clopidrogel 1week Ticlopidine 14 days Add heparin if need anticoagulation

 7. Prepare blood/PRC (6-15 units), FFP 10-20 ml/kg, plateletpheresis or platelet concentrate (10-20 units), cryoprecipitate 10-20 units 8. Discuss anesthetic and operative plan with the surgical team to properly prepared for all possible contingencies. 9. Assess risk of pulmonary aspiration 10. Plan for CPB, left heart bypass or circulatory arrest

Room Preparation 1. Equipments

Single lumen ETT, double lumen ETT, endobronchial blocker Equipments assisted difficult intubation Infusion pump x 3 , Syringe pump x 3 Warmer : water-bath x 1, forced-air warmer x 1, mini-warmer apparatus x 2 IV set infusion x 5, Blood/blood component infusion set x 10 Rapid infuser system(1500ml/min) Extension tubings, Three-ways x 10 IV cannulas of different sizes Double-lumen , triple lumen IV catheter Swan ganz catheter 7Fr x 1 + Terrumo sheath introducer 8 Fr x 1

2. DRUGS :
Cardiovascular drugs
Adrenalin (0.1 mg/ml) = 10 ml for IV bolus Atropine (0.6 mg/ml) norepinephrine : Bolus(0.1ug/kg) ,220ug/min infusion dopamine (1-20ug/kg/min) Nitroprusside (100ug/ml) ; IV infusion(0.5-10ug/kg/min Nitroglycerin (100 ug/ ml) = 100 ml for IV infusion
Esmolol (0.2-0.5mg/kg);50-200ug/kg/min Phenylephrine 50-100ug;0.25-1ug/kg/min

For decreasing postop bleeding :

- Transamin 10-20 mg/kg IV bolus Aprotinin 280mg; 3mg/kg/hr -Desmopressin 0.3 g/kg IV -EACA 5-10g f/by 1g/hr

- Recombinant activated factor VIIa (Novoseven) 90 g/kg IV,

Others :
Diuretics: 25% mannitol 0.25-1 gm/kg Furosemide 40 mg/ml
Antiarrhymic agents: xylocard, cordarone (150 ml/3 ml/amp), MgSO4 (2 gm) Sodium bicarb 50 ml/amp

Anticoagulant:

Heparin 1 mg (100 units)/kg 10% Calcium gluconate/chloride 10 ml/amp without using CPB Antibiotics : Heparin 3 mg (300 units) kg Humulin R and 50% glucose 50 ml x 2 when using CPB

Premedication
Patient should be brought in preoperative ward 1 hr before surgery Secure large bore intravascular access Alleviate fear, anxiety and pain Midazolam 0.01-0.15mg/kg i/v Morphine 0.05-0.1mg/kg i/m or fentanyl 0.5-1ug/kg i/v Continue cardiac medications till morning of surgery Small oral dose of clonidine 2ug/kg reduce incidence of perioperative MI without affecting hemodynamics Catheterize patient and note urinary output

MONITORING:
HEMODYNAMIC MONITORING:

Continuous ECG, NIBP,pusle oximetery,EtC02, Intra-arterial catheter: (IBP)

Right Radial artery, Left radial artery, Femoral artery or dorsalis pedis artery

Central venous catheterization Pulmonary artery catheterization Transesophageal echocardiography: TEE

provide diagnostic information, assessment of ventricular function and intravascular volume status

Neurophysiologic monitoring Electroencephalography (EEG)

Evoked potentials: Somatosensory(SSEP); Motor (MEP)

(to detect spinal cord ischemia) Lumbar CSF pressure Jugular venous bulb O2 saturation

Temperature monitoring:
Upper body core temp. : nasopharyngeal or esophageal Lower body core temp. : bladder, rectal

Others:
Arterial blood gases, electrolytes (Na+, K+, Ca++), Hct Activated clotting time (ACT), (Coagulogram) Blood sugar Urine output Estimated blood loss

Intra-operative management
Position : Discuss with the surgeon
Supine for median sternotomy and endovascular stent repair Right lateral decubitus for left thoracotomy

Operative techniques for repair of TAAA

Simple aortic cross clamping/ clamp -and-sew technique Passive GOTT shunt Left Heart bypass Deep hypothermic circulatory arrest

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Performed without ECC support. Surgical simplicity. Obligatory ischemia to organs distal to clamp Increased incidence of paraplegia and renal failure Cross-clamp time should not exceed 30 minutes Proximal aortic hypertension, bleeding from arterial collaterals, hemodynamic instability upon reperfusion COMPANY LOGO

 Increased arterial blood pressure above the clamp Decreased arterial blood pressure below the clamp Clamping of the increases : mean arterial pressure by 35%
Central venous pressure by 56% Mean pulmonary arterial pr by 43% Pulmonary capillary wedge pr by 90%

HR & LV stroke work do not changed significantly LV wall tension Ejection fraction coronary blood flow

AT SUPRACELIAC AORTIC CROSS-CLAMPING: MAP increase by 54% PCWP by 38% EF decreases by 38% Significant wall motion abnormalities AT SUPRARENAL LEVEL: similar but smaller CVS changes AT INFRARENAL LEVEL: minimal cnanges with no wall motion abnormalities

Blood volume redistribution hypothesis

Metabolic changes

Total body 02 consumption Total body CO2 production Respiratory alkalosis mixed venous O2 saturation Metabolic acidosis total body O2 extraction epinephrine & norepinephrine Tissue perfusion distal to cross clamp depends on proximal aortic pressure & independent of CO. Renal blood flow markedly decrease ( 83-90%) during thoracic aortic cross clamping Increased plasma renin activity, other mediators like plasma endothelin, myoglobin, PGs contribute to decreased renal perfusion

Therapeutic interventions
Afterload reduction
Sodium nitroprusside Inhaled anaesthetics Amrinone Shunts and aortofemoral bypass

Preload reduction
Nitroglycerin Controlled phlebotomy Atrial to femoral bypass

Renal protection
Fluid administration Distal aortic perfusion techniques Selective renal artery perfusion Mannitol and drugs to augment renal perfusion

 Hypotension Decrease myocardial contractility Decrease CO

METABOLIC:
Inc total body O2 consumption Decrease mixed venous O2 saturation Metabolic acidosis

Therapeutic intervention: inhaled anaesthetic vasodilators fluid administration vasoconstrictors Sodium bicarbonate Reapply clamp for severe hypotension

Aortic unclamping

 Tapered heparin coated tube so that both ends can serve as arterial cannulas Proximal cannulation sites: ascending aorta or aortic arch Distal cannulation sites: distal descending thoracic aorta, iliac artery or femoral artery Passive shunting of blood from proximal to distal aorta Simple, inexpensive, requires only partial or no anticoagulation
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Partial left heart bypass

Left atrial- to- femoral bypass Partial heparinazation i.e 100U/kg reqd. 5 minutes before cannulation Initial flow rate of 500ml/min Mean arterial pressue of 80-100mmhg above the cross clamp and atleast 60mmhg below the cross clamp Moderate hypothermia 32C

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Proximal aortic anastomosis

visceral aortic anastomosis

distal aortic anastomosis

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Deep hypothermic circulatory aresst

Surgery of arch of aorta Profound hypothermia of 15*C 30 minutes safe limit of DHCA With selective antero or retrograde cerebral perfusion with cold oxygenated safe limit of 90mins Femoral-femoral bypass

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Surgery involving ascending aorta

Median sternotomy Cardiopulmonary bypass Intra-operative course may be complicated by aorti c regurgitation, long cross-clamping time, large intr a-operative blood loss Left radial artery for IBP Drugs causing bradycardia should be used cautiously. Left ventricular vent is necessary during CBP wheat procedure Bentall procedure
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 To Maintain hemodynamic stability during induction, intubation and maintenance of anesthesia with cardiac, vasoactive and fluid management To prevent rupture of aneurysm(during induction) Gentle laryngoscopy and endotracheal / endobronchial intubation Avoid hypo or hyperthermia

Organ protection: myocardium, CNS, spinal

cord,kidney,mesentries Prevention and management of hemorrhage and coagulopathy

Anaesthetic technique:
Induction
Slow & controlled PREOXYGENATION No single best anaesthetic technique Intravenous induction agents: etomidate, propofol, thiopental or ketamine(severe hypotension) Combination with fentanyl(3-5ug/kg) and midazolam 1-2mg IV or low dose volatile anaesthetic

 SBP b/w 105-115mmhg HR b/w 60-80 b/min CI b/w 2-2.5L/min/m2

ESMOLOL (10-25MG), NITROPRUSSIDE (5-25uG), NTG(50100uG) PHENYLEPHRINE(50-100uG) Should be available for bolus if needed

Intubation:
Consider emergent and urgent patient as full stomach. Rapid sequence induction and intubation should be performed Succinylcholine or short-acting NDP (cis-atracurium can be used

One lung ventilation

For left thoracotomy or TAAA incision Double-lumen endobronchial (DLT) tube(left-sided DLT) or single lumen ETT with endobronchial blocker Exchanging the DLT at the end of procedure can be difficult as the airway may be edematous use of Tube exchange catheter
Equipments for emergency airway

 Combination of O2, N2O, potent opoids(fentanyl, sufentanil), Low dose potent volatile agents(isoflurane, sevoflurane,desflurane. Muscle relaxant: preferred
Vecuronium,0.08-0.12 mg/kg Rocuronium,0.45-0.9mg/kg Cisatracurium0.1-0.15 mg/kg

TIVA may be optimal if transcranial MEP monitoring is used Nitroprusside (0.5-2ug/kg/min )and esmolol (25300ug/kg/min) infusion EXTUBATION should always take place in the ICU & only after a significant period of hemodynamic & metabolic stability

Throacoabdominal aortic aneurysm extent Hypotension or cadiogenic shock Emergency operation Aortic rupture Presence of aortic dissection Duration of aortic cross clamp Surgical technique used for repair Prior aortic aneurysm repair Occulsive peripheral vascular disease

Detection of spinal cord ischemia

Somatosensory evoked potentials Motor evoked potentials

Immediate onset paraplegia Delayed onset paraplegia

Strategies used for spinal cord protection

MINIMIZE AORTIC CROSS-CLAMP TIME Distal aortic perfusion Passive shunt Partial left heart bypass Partial cardiopulmonary bypass INCREASE SPINAL CORD PERFUSION PRESSURE Re-implantation of critical intercostal & segmental arterial branches Lumbar CSF drainage Arterial pressure augmentation (MAP> 85mmhg)

Lumbar CSF drainage

SCPP= distal MAP CSF pressure or CVP Silicon catheter at L3 & L4 interspace

CSF allowed to drain when CSF pressure exceeds 10 mmHg

Complications:extradural/intradural hematoma, Catheter fracture,intracranial hypotension, headache, mennigitis, subdural hematoma

ARTERIAL PRESSURE AUGMENTATION Maintain MAP in range of 80-100mmhg Spnal cord perfusion pressure above 70mmhg Decreasing lumbar CSF pressure alone may have negligible effect if MAP is insufficient

Deliberate hypothermia

Pre-operative spinal cord angiogaphy

for Identifation of great radicular artery(GRA): decreases risk of paraplegia

Intra-operative monitoring of lower extremity neurophysiologic function

SSEPs: dec in amplitude &latency of SSEP > 1430minutes increases risk of neurologic deficit

MEPs

Post-operative neurologic assessment for early detection of delayed onset paraplegia by serial neurologic examinations

Renal ischemia &protection

Distal aortic perfusion maintains renal blood flow during proximal anastomosis Cathertization of renal arteries and perfusion with iced saline to maintain regional hypothermia below15C Mannitol (0.25g/kg) before cross-clamping improves renal blood flow. Loop diuretics less effective Low dose dopamine(1-3ug/kg/min) Fenoldopam mesylate(0.1ug/kg/min)a selective dopamine type 1 agonist dilates renal &splanchic vascular beds

Blood loss & coagulopathy

Blood loss and transfusion therapy are commonplace Dilutional coagulopathy common
( low level of platelets, clotting factors, residual heparin, ischemia of liver,persistent hypothemia)

Transfusion of platelets, FFPs, cryoprecipitates

Monitor PT, aPTT, fibrinogen level, platelet count

Antifibrinolytic therapy:
E aminocaproic acid 5-10gm f/by 1gm/hr; tranexamic acid 10mg/kg f/by 1mg/kg/hr Desmopressin : to increase level of von-willibrand factor& factorVIII Recombinant activated factor VIIa 90ug/kg i/v; repeated after 2 hours

Complete rewarming

 Arterial blood gases and electrolytes should be measured frequently. Sodium bicarbonate to correct severe metabolic acidosis(pH<7.20): 1-3meq/kg/hr Calcium chloride may be necessary following massive tranfusion of citrated blood products Hyperkalemia should be treated aggressively esp. in oliguric or anuric patients

Post-operative analgesia
Thoracotomy & TAAA incision very painful, cause respiratory splinting, retention of airway secretions post-operative respirtory failure Epidural analgesia is effective means of providing intra-op &post-op analgesia Epidural analgesia regimen should be formulated to minimise interference with ability to monitor lower extremity neurologic function and not cause sympathetic blockade Bupivicaine 0.05% combined with fentanyl 2ug/ml via PCEA infusion @ 4-8ml/hr Bolus administration should be avoided. Epidural catheter can be inserted prior to, at the time of surgery, or in the post-operative period Coagulation parameteres should be satisfactory prior to insertion and during removal of catheter

Thankyou

THE SITUATION

AAAs are the tenth leading cause of death in men over 50.

An estimated 1 million men and women worldwide are living with undiagnosed AAAs.

Could your patient have an undiagnosed AAA?

AAA
Diameter > 3cm Atherosclerosis & aging Infrarenal arota: no vasa vasorum
Prevalence: 10% in men, 3% in women Perioperative mortality with elective repair: 2-5% Emergency repair : 50% When AAAs rupture, only 18% of patients survive.

Size of AAA directly related to morbidity and risk of rupture >5cm diameter - incidence of rupture substantially 1 year incidence of probable rupture- 35% for aneurysm > 7cm Mural thrombosis are common

SYMPTOMS
Asymptomatc Palpable, pulsatile ,non-tender mass on routine exam/ incidental finding during imaging of abdomen Pain or tenderness in the lower back, abdomen Indications of rupture may include: Lightheadedness Sweating Clammy skin Nausea/vomitting Shock palpable/ pulsatile abdominal mass; hypotension (<1/3 cases)

classic triad: abdominal or back pain;

DIAGNOSIS
Physical examination of abdomen
Pulsatile, palpable abdominal mass Stiff /rigid abdomen Bruit over the aorta

Abdominal ultrasound , may detect mural thrombosis As required: MRI, CT or other imaging systems Angiography rarely done CTA

Abdominal radiography :

TREATMENT OPTIONS

Medical management/monitoring(watchful waiting) :AAAs <5.5cm Open surgery: AAAs exceeds 5.5cm Endovascular repair
No proven lifestyle changes can decrease the size of TAAs.
TEVAR animation video