Title : Patterns of anaesthesia choice during endovascular aortic aneurysm repair: 15-year trends at a regional vascular Centre in Australia
Abstract:
Aims: Endovascular aortic aneurysm repair (EVAR) has become an increasingly adopted intervention for aortic aneurysms in both elective and emergency settings. A recent systematic review comparing general anaesthesia (GA) vs local anaesthesia (LA) for EVAR demonstrated a significant benefit in LA across multiple outcomes including lower in-hospital stay as well as lower rates of myocardial infarction, pneumonia and mortality.(1) With enhanced recovery after surgery (ERAS) generating a significant amount of research interest in recent years, the use of LA in EVAR may be an appropriate strategy for implementation to optimise ERAS protocols. We sought to explore anaesthesia trends within a regional centre that provides Vascular Surgery care for Tasmania in relation to the use of GA and LA.
Methodology: A 15-year retrospective analysis of all EVARs performed within Tasmania was performed. General patient demographics were extracted including age, sex and key comorbidities (ischaemic heart disease, hypertension, diabetes, chronic kidney disease and smoking status). The primary data points of interest included year of procedure, indication for EVAR, comorbidities and anaesthetic choice (GA vs LA / regional). A sub-analysis of GA vs LA was performed in relation to indications, cases per year and length of stay in order to identify usage patterns of LA in EVAR.
Results: A total of 385 EVARs were performed across the 15-year period by a total of seven Vascular Surgeons. Of these, abdominal aortic aneurysms (AAA) were the most common type of aneurysm (90.6%), followed by thoracic aortic aneurysms (4.7%), common iliac aneurysm (3.1%), and branched / fenestrated thoracoabdominal aortic aneurysms (1.5%). The significant majority of patients were male (83.9%) with a mean age of 73.7 (range 22 - 94). Patients had a broad range of comorbidities with most common being hypertension (76.3%), and ischaemic heart disease (46.5%). The most common indication for EVAR was elective aneurysm (78.6%), followed by symptomatic / ruptured aortic aneurysms (18.4%) and mycotic aneurysms (2.6%). GA was used in the vast majority of cases (91.7%) compared to LA with no increased use of LA use across years. Of the 32 LA cases, 24 were utilised in ruptured / symptomatic aortic aneurysms with only 8 being elective aneurysms. When looking at length of stay of elective EVARs, all LA cases (8/8) were discharged on day-one postoperatively, compared to only 46.7% of GA cases. A further 42.9% of GA EVARs were discharged on days two to five postoperatively.
Conckusion: In conclusion, this analysis has shown that there remains little uptake of the use of LA for elective EVAR with the most common use-case continuing to be in symptomatic / ruptured aortic aneurysm cases. There are many reasons that GA may be preferred in elective EVAR (surgeon preference, patient preference, ease of ventilatory pause for angiograms), however, in light of recent evidence in literature and patterns of recovery in our retrospective review, this review suggests that LA-based EVAR may be an effective way to enhance recovery after surgery in EVAR.
