Percutaneous endovascular abdominal aortic aneurysm repair with monitored anesthesia care decreases operative time but not pulmonary complications

Q: What are the key findings of this study?

PEVAR under monitored anesthesia care reduced operative time (106 vs. 134 min, P<0.001) compared to general anesthesia without reducing 30-day pulmonary complications (2.2% vs. 2.9%, P=0.835).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Abdominal aortic aneurysm undergoing endovascular repair (n=159). Intervention: Percutaneous endovascular aortic aneurysm repair (PEVAR) under monitored anesthesia care (MAC) with local anesthesia vs. PEVAR under general anesthesia (GA). Primary outcome: Operative time (minutes) (p=<0.001).

Q: What does this research mean for the field?

Percutaneous endovascular abdominal aortic aneurysm repair under monitored anesthesia care reduces operative time and blood loss compared to general anesthesia but does not reduce postoperative pulmonary complications. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To compare the perioperative outcomes and complication rates of percutaneous endovascular abdominal aortic aneurysm repair performed under monitored anesthesia care versus general anesthesia.

Joshua P. Kronenfeld; Emily L. Ryon; Alex Lall; Naixin Kang; Stefan Kénel-Pierre; Hilene DeAmorim; Jorge Rey; John Karwowski; Arash Bornak

doi:10.1177/17085381211012908

May 3, 2021VascularOpen Access

Percutaneous endovascular abdominal aortic aneurysm repair with monitored anesthesia care decreases operative time but not pulmonary complications

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Key result

PEVAR under MAC cuts operative time by ~28 minutes vs. general anesthesia without pulmonary benefit.

P<0.001
n=159

Why the study?

The authors aimed to evaluate and compare outcomes of percutaneous endovascular aortic aneurysm repair performed under monitored anesthesia care versus general anesthesia.

Does performing percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) under monitored anesthesia care (MAC) decrease operative time and 30-day postoperative pulmonary complications compared to general anesthesia (GA)?

Key Points

To compare the perioperative outcomes and complication rates of percutaneous endovascular abdominal aortic aneurysm repair performed under monitored anesthesia care versus general anesthesia.
Retrospective review of 159 male patients undergoing non-emergency endovascular abdominal aortic aneurysm repair at a single institution, excluding complex repairs.
Evaluated 115 percutaneous repairs (45 under monitored anesthesia care and 70 under general anesthesia) and 44 repairs requiring femoral cutdown.
No statistically significant differences occurred between monitored anesthesia care and general anesthesia for hospital length of stay (1.9 vs. 2.7 days, P = 0.133) or postoperative pulmonary complications (2.2 vs. 2.9%, P = 0.835).
Conversion from percutaneous repair to femoral cutdown (n = 14) had higher estimated blood loss (543 vs. 323 mL, P = 0.03), operative time (230 vs. 178 min, P = 0.01), and operating room time (307 vs. 275 min, P = 0.01) than planned femoral cutdown.

Study Design

Type

Cohort (n=159)

Multicenter

No

Structured PICO

Does performing percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) under monitored anesthesia care (MAC) decrease operative time and 30-day postoperative pulmonary complications compared to general anesthesia (GA)?

P

Population

159 male veterans (median age 69) undergoing primary non-emergency endovascular abdominal aortic aneurysm repair at a single US VA hospital, followed for 30 days.

E

Exposure

Percutaneous endovascular aortic aneurysm repair (PEVAR) performed under monitored anesthesia care (MAC) using IV dexmedetomidine, midazolam, and fentanyl combined with local lidocaine and percutaneous suture-mediated closure (n=45)

C

Comparator

PEVAR performed under general anesthesia (GA) (n=70); secondary comparison with EVAR using femoral artery cutdown (FC) (n=44)

O

Outcome

Intraoperative metrics including operative time and total operating room time, and 30-day postoperative pulmonary complications (pneumonia, COPD exacerbation)safety

Main Result

Absolute Event Rate: 106% vs 134%

p-value: p=<0.001

PEVAR under monitored anesthesia care safely reduces operative and operating room times and estimated blood loss compared to general anesthesia, although it does not reduce 30-day pulmonary complications or hospital length of stay.

Limitations

Relatively small number of patients involved
All studied patients were male due to the VA hospital population
Single-institution retrospective medical record review
Potential selection bias with challenging aortic anatomy performed under GA in the early experience
Relatively small sample size (n=159 total, n=115 PEVAR)
100% male cohort from a single Veterans Affairs hospital, limiting generalizability to females
Retrospective study design with inherent medical record review limitations
Potential selection bias and confounding, particularly in the early experience where GA was favored

Implication

MAC may shorten PEVAR operative time without reducing pulmonary complications; leaves open need for RCTs to guide anesthesia choice.

Abstract

Objectives To report our experience and compare the results of percutaneous endovascular aortic aneurysm repair (PEVAR) performed under monitored anesthesia care (MAC) to PEVAR under general anesthesia (GA). Methods A retrospective review of patients who underwent non-emergency endovascular abdominal aortic aneurysm repair (EVAR) was completed. Patients were excluded if they had a complex repair, including fenestrated, branched, or parallel endografting. Demographics, operative data, 30-day mortality/morbidity and postoperative outcomes were analyzed. Results A total of 159 patients were identified with a median age of 69. 115 patients had PEVAR, 45 (39.1%) PEVAR MAC and 70 (60.9%) PEVAR GA. PEVAR MAC compared to PEVAR GA had decreased operative time (106 vs. 134 min, P < 0.001), time in the operating room (163 vs. 245 min, P = 0.016), and estimated blood loss (EBL) (115 vs. 176 mL P = 0.012). There was no statistically significant difference in the hospital length of stay (LOS) (1.9 vs. 2.7 days, P = 0.133), and post-operative complications including pulmonary (2.2 vs. 2.9%, P = 0.835). Forty-four patients had EVAR with a femoral cutdown (FC), including 14 PEVAR conversions. PEVAR conversion was associated with higher EBL (543 vs. 323 mL, P = 0.03), operative time (230 vs. 178 min, P = 0.01), and operating room time (307 vs. 275 min, P = 0.01) compared to planned EVAR with FC. Conclusions PEVAR under MAC is associated with shorter time in the operating room compared to PEVAR under GA. PEVAR under MAC does however not decrease overall morbidities, including postoperative pulmonary complications.

Discussion

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Cite This Study

Kronenfeld et al. (2021) conducted a cohort in Abdominal aortic aneurysm undergoing endovascular repair (n=159). Percutaneous endovascular aortic aneurysm repair (PEVAR) under monitored anesthesia care (MAC) with local anesthesia vs. PEVAR under general anesthesia (GA) was evaluated on Operative time (minutes) (p=<0.001). PEVAR under monitored anesthesia care reduced operative time (106 vs. 134 min, P<0.001) compared to general anesthesia without reducing 30-day pulmonary complications (2.2% vs. 2.9%, P=0.835).

synapsesocial.com/papers/6a747c0ef5fc3941440326bf https://doi.org/10.1177/17085381211012908

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Percutaneous endovascular abdominal aortic aneurysm repair with monitored anesthesia care decreases operative time but not pulmonary complications

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Percutaneous endovascular abdominal aortic aneurysm repair with monitored anesthesia care decreases operative time but not pulmonary complications

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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