ABSTRACT
Spinal cord ischemia (SCI) is a rare presenting symptom of acute complicated type B aortic dissection, occurring in approximately 3% of patients . We present a case report of a patient with this presentation who had observed resolution of his paraplegia symptoms immediately after placement of a thoracic stent graft under local anesthesia. The temporal association between true lumen flow restoration and paraplegia resolution intraoperatively is a novel finding. We feel that this case report may provide support for recognized cord perfusion theory , as well as contribute to the understanding of the time frame associated with SCI and reversibility of paraplegia.
Subject(s)
Anesthesia, Local , Aortic Aneurysm, Thoracic/surgery , Aortic Dissection/surgery , Blood Vessel Prosthesis Implantation , Endovascular Procedures , Lower Extremity/innervation , Paraplegia/etiology , Spinal Cord Ischemia/etiology , Acute Disease , Aged , Aortic Dissection/complications , Aortic Dissection/diagnostic imaging , Aortic Aneurysm, Thoracic/complications , Aortic Aneurysm, Thoracic/diagnostic imaging , Endovascular Procedures/adverse effects , Humans , Male , Paraplegia/diagnosis , Paraplegia/physiopathology , Recovery of Function , Spinal Cord Ischemia/diagnosis , Spinal Cord Ischemia/physiopathology , Treatment OutcomeABSTRACT
BACKGROUND: Endovascular aneurysm repair (EVAR) is an accepted approach for patients presenting with ruptured abdominal aortic aneurysm (rAAA) and suitable anatomy. The effect of anesthesia modality on mortality outcomes in rAAA has not been well described. Using the Vascular Quality Initiative database, this study compares local anesthesia (LA) vs general anesthesia (GA) in EVAR for rAAA. METHODS: The Vascular Quality Initiative database was queried for patients presenting with rAAA managed with open surgical repair, EVAR under LA (rEVAR-LA), and EVAR under GA (rEVAR-GA) between 2003 and 2017. Patients were observed until the earlier end point of either death or 1-year follow-up. Kaplan-Meier event rates are presented at 30 days and 1 year. Cox proportional hazards regression was used to model risk of death, with adjustment for demographic and clinical factors. Additional multivariate Cox hazards analyses were used to assess effect modifiers for 1-year mortality for the different repair methods. RESULTS: A total of 3330 patients (77.4% male) met the inclusion criteria (1594 [47.9%] open surgical repair, 226 [6.8%] rEVAR-LA, and 1510 [45.3%] rEVAR-GA). Patients treated with rEVAR-LA compared with rEVAR-GA had decreased intraoperative time, number of intraoperative blood transfusions, intraoperative crystalloid administration, intensive care unit length of stay, and postoperative pulmonary complications. Mortality rates with rEVAR-LA were lower compared with rEVAR-GA at 30 days (15.5% vs 23.3%; adjusted hazard ratio [AHR], 0.70; 95% confidence interval [CI], 0.49-0.99; P = .04) and at 1 year (22.5% vs 32.3%; AHR, 0.71; 95% CI, 0.53-0.96; P = .02). Patients undergoing EVAR who were <75 years old and those without preoperative hypotension had the greatest survival benefit from LA compared with GA (both factors: AHR, 0.14 [95% CI, 0.03-0.57]; single factor: AHR, 0.57 [95% CI, 0.36-0.91]). CONCLUSIONS: This study demonstrates that rEVAR-LA for rAAA may be a safe alternative to rEVAR-GA for certain patients, with lower morbidity and improved mortality. Further prospective study is warranted to confirm mortality benefit in rEVAR-LA for rAAA.
Subject(s)
Anesthesia, General , Anesthesia, Local , Aortic Aneurysm, Abdominal/surgery , Aortic Rupture/surgery , Blood Vessel Prosthesis Implantation , Endovascular Procedures , Aged , Anesthesia, General/adverse effects , Anesthesia, General/mortality , Anesthesia, Local/adverse effects , Anesthesia, Local/mortality , Aortic Aneurysm, Abdominal/diagnostic imaging , Aortic Aneurysm, Abdominal/mortality , Aortic Rupture/diagnostic imaging , Aortic Rupture/mortality , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/mortality , Databases, Factual , Endovascular Procedures/adverse effects , Endovascular Procedures/mortality , Female , Humans , Male , Postoperative Complications/mortality , Postoperative Complications/therapy , Registries , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: The aim of this study was to report the results of percutaneous endovascular aortic aneurysm repair (PEVAR) using the superficial femoral artery (SFA) for large bore vessel access. METHODS: We reviewed all PEVAR procedures at our institution over an 18-month period, identifying all patients who underwent PEVAR with the use of one or both SFAs for endograft delivery with dual ProGlide large bore access closure. Indications for use of the SFA instead of the common femoral artery (CFA) included morbid obesity, CFA vessel wall disease, and scarring from previous CFA surgery. RESULTS: In total, 158 percutaneous access closures were performed in 79 patients. Ten patients had one or both SFAs used. We accessed a total of 13 SFAs: 6 for the endograft main body (size range 18- to 20-French) and 7 for the limb (14- to 16-French). The freedom from open conversion was 84.6%. In comparison, of 145 CFA accesses (in 76 patients) there were 9 conversions (93.7% success). Of the 13 SFAs accessed, there were no major access site complications (pseudoaneurysm, access site bleed, limb ischemia, or need to return to the operating room). All SFAs accessed remained patent at the latest follow-up (range 1-13 months, median 8 months). CONCLUSIONS: Our preliminary case series suggests that, in the absence of a healthy or percutaneously accessible CFA, a healthy SFA may be considered for PEVAR access. While likely carrying a higher risk of open conversion, this technique, when combined with intraoperative duplex ultrasound (both before and after the procedure) and with meticulous ultrasound-guided vascular access, appears safe for up to 20-French device diameters.
