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AAA stent and anesthetic consideration
Presented by 劉志中
Patient profile
• 82y/o ,female• Past history: 1.DM 2.HTN for 40 years 3.CAD ,two vessels (RCA,LCX) s/p POBAS 4.paroxysmal Af with RVR 5. left renal artery stenosis s/p stenting
Present illness
2004/10 pulsatile abdominal mass ,echo and CT revealed AAA at 埔基2004/11 came to NTUH an episode of chest tightness with ST-T depression and T inversion over V4-6 on ECG, Af with RVR s/p codarone control2004/11 Cardiac cath:CAD,2VD s/p POBAS carotid duplex: bilateral carotid a. stenosis and vertebral a. flow insufficiency2005/1/6 AAA stent
Induction agent
• Fentanyl 100ug
• Atropine 0.5mg
• Etomidate 18mg
• Succinylcholine 70mg
• Cistracurium 10 mg+ continuous infusion
• NTG:0.1ml x 2
Intraoperative mantainace
• Sevoflurane
• Intermittent bolus : fentanyl (total dosage:150ug)
Op procedure
• ETGA ,supine
• Bilateral femoral a. cut-down and expose
• L. femeral a. sheath insertion and put into a pig tail
• R. femeral a. sheath insertion and put into the main body of AAA stent
• Expended the stent….
Video time
What we have to know
• Open vs. Stent graft
• What kind of patients will we meet ?
• Anesthetic plan
• Intraoperative monitoring and surgical complications
• Post operation care
Open vs.Stent-graft
• Open AAA repair is still the first choice of therapy currently
• While aged patient ,increased co-morbidity,
the cost and benefit of this traditional open
surgery should be weighed
An analysis of standard open and Endovascular surgical repair of AAA in Octogenarians• Endovascular surgical repair of AAA has
the advantages as follows:
1. less blood loss
2. shorter ICU stay
3. shorter hospital stay
4. less blood transfusion
5. less cardiopulmonary complicationsThe American surgeon 2003,Sep;744-748
What kind of patients will we meet ?
• The patient who presents for elective repair of an abdominal aortic aneurysm often has additional
1.hypertension (55%) 2.CAD (73.5%) 3.peripheral vascular disease (21%) 4.stroke and transient ischemic attack(22%) 5.DM(7%) 6.renal insufficiency (10%) 7.smoking history (80%)
Vasc Surg 2001;35:335-44
Anesthetic plan
• General vs. regional
No difference in overall cardiac and
pulmonary morbidity and mortality
J Vasc Surg 2002;36:988-91
• Appropriate monitoring :depends on patients coexisting disease.
• Central venous access
• Avoid cardiosuppression drugs as possibleAnesthesiol Clin N Am,22(2004)251-64
Intraoperative monitoring
• Pulse oximetry
• ECG (5 lead)
• A- line
• Foley
• Temperature
• CVP
• PAP
• TEE
Surgical complications
• Arterial injury ,device implant failed• Device occlusion,stenosis,migration• Endoleak
1.type I: inadequate seal at proximal of
distal segments of the endoprosthesis
2.type II:brach flow through patent accessory
renal,IMA,hypogastric,lumbar or sacral a.
3. type III: midgraft leak through a fabric hole or
inadequate seal between graft components Anesthesiol Clin N Am,22(2004)319-32
The risk of late failure is 3% per year, the continued presence of the risk of aneurysm rupture is 1% per year
Post op care
• Not routinely required ICU stay if uncomplicated• Prolonged mechanical ventilation may be indicat
ed if major intra-op bleeding, MI,renal failure,bowel ischemia,sepsis syndrome,or ARDS.
• Close hemodynamic monitoring• Adequate analgesia:opioid , NSAID,neuro-axial
block.• Postimplantation syndrome: fever,leukocytosis,a
nd increased CRP.
Thanks for your attention!!