Local anesthesia for percutaneous endovascular abdominal aortic aneurysm repair is associated with fewer pulmonary complications

Orden, Kathryn Van; Farber, Alik; Schermerhorn, Marc L.; Goodney, Philip P.; Kalish, Jeffrey; Jones, Douglas W.; Rybin, Denis; Siracuse, Jeffrey J.

doi:10.1016/j.jvs.2017.12.064

Cited by 32 publications

(18 citation statements)

References 21 publications

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“…Twenty-two studies met the inclusion criteria ( Figure 1). A summary of the 22 selected studies, which date from 1996 to 2018, is shown in Table 1 14,16,18,[22][23][24][25][26][27][28][29][30][31][32][33]39,40,[43][44][45][46][47] . Twelve of these studies were not included in previous reviews 16,18,22,23,33,39,40,[43][44][45][46][47] .…”

Section: Studies Retrievedmentioning

confidence: 99%

“…Most studies (14/22) included only patients who had elective EVAR surgery. Three studies included a mix of elective and emergency surgery, although most patients were in the elective group 23,31,46 . Four articles focused exclusively on emergency EVAR: the secondary analysis of the IMPROVE trial 18 (186 patients) and three retrospective database analyses 39,40,47 (total 3183 patients).…”

Section: Elective/emergency Splitmentioning

confidence: 99%

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Type of Anesthesia for Endovascular Abdominal Aortic Aneurysm Repair

Armstrong

Squire

Rogers

et al. 2019

Journal of Cardiothoracic and Vascular Anesthesia

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Objective: Endovascular aneurysm repair (EVAR) is increasingly used in the management of patients with abdominal aortic aneurysms (AAA), including in the emergency setting for ruptured AAA. The lower mortality amongst patients undergoing emergency EVAR under local anesthesia (LA) observed in the IMPROVE trial has sparked renewed interest in the anesthesia choice for EVAR. This systematic review evaluates the effect of mode of anesthesia on outcomes after EVAR. Design: The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was inhospital/30-day mortality and both emergency and elective EVAR were included. The relative risk of death was estimated for each individual study without adjustment for potential confounding factors. Setting: Hospitals. Participants: A total of 39,744 patients from 22 non-randomized studies were included in the analysis. Interventions: None Measurements and Main Results: Sixteen studies in 23,202 patients compared LA to GA and reported in-hospital/30-day mortality. The unadjusted risk of death after emergency EVAR with LA was lower than with GA. Trends in elective surgery were less clear. Conclusions: There is some evidence across both emergency and elective settings to suggest that mode of anesthesia may be associated with improved outcomes. In particular, 3 LA appears to have a positive effect on outcome after emergency EVAR. Due to the lack of randomized trial data, a significant risk of confounding remains. The optimal mode of anesthesia for EVAR should be further investigated and the reasons why particular anesthesia techniques are chosen for particular patients identified.

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Section: Studies Retrievedmentioning

confidence: 99%

Section: Elective/emergency Splitmentioning

confidence: 99%

Type of Anesthesia for Endovascular Abdominal Aortic Aneurysm Repair

Armstrong

Squire

Rogers

et al. 2019

Journal of Cardiothoracic and Vascular Anesthesia

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“…1 With EVAR becoming more common, many institutions have transitioned from routinely admitting patients to the ICU to admitting them to lower levels of care such as a step-down unit or a regular surgical floor; some have even adopted same day discharge. [1][2][3][4][5] However, in current practice, acuity of postoperative care continues to vary for EVAR. [1][2][3][4][5] One study reported a significant discrepancy in ICU utilization following an EVAR as patients who were directly admitted to the ICU after an EVAR were at hospitals where most (96.7%) patients were admitted to the ICU after an EVAR.…”

Section: Introductionmentioning

confidence: 99%

Perioperative Outcomes for Centers Routinely Admitting Postoperative Endovascular Aortic Aneurysm Repair to the ICU

Cheng

Farber

Levin

et al. 2021

Journal of the American College of Surgeons

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BACKGROUND: Intensive care unit (ICU) admission after endovascular aortic aneurysm repair (EVAR) varies across medical centers. We evaluated the association of postoperative ICU use with perioperative and long-term outcomes after EVAR. STUDY DESIGN: The Vascular Quality Initiative (2003–2019) was queried for index elective EVARs. Included centers were categorized by percentage of patients with EVARs postoperatively admitted to the ICU; routine ICU (rICU) centers as ≥80% ICU admissions and nonroutine ICU (nrICU) centers as ≤20% ICU admissions. Patients admitted preoperatively or with same day discharge were excluded. Perioperative outcomes and survival were compared between rICU and nrICU centers. RESULTS: Of 45,310 EVARs in the database, 35,617 were performed at rICU or nrICU centers – 5,443 (15.3%) at 71 rICU centers and 30,174 (84.7%) at 200 nrICU centers. Overall, mean age was 73.4 years and 81.6% were male. Postoperative myocardial infarction, pulmonary complications, stroke, leg ischemia, and in-hospital mortality were similar between rICU and nrICU centers (all p > 0.05). Postoperative length of stay (LOS) was prolonged at rICU centers (mean) (2.2 ± 3.6 vs 2 ± 4.2 days, p < 0.001). One-year survival was similar between rICU and nrICU centers, respectively, (94.9% vs 95.4%, p = 0.085). When compared with nrICU centers, rICU centers had similar 1-year mortality risk (hazard ratio [HR] 1.15, 95% CI 0.99–1.34, p = 0.076), but were associated with longer postoperative LOS (means ratio 1.1, 95% CI 1.08–1.13, p < 0.001). CONCLUSIONS: Routine ICU use after EVAR was associated with prolonged postoperative LOS, without improved perioperative/long-term morbidity or mortality. Updated care pathways to include postoperative admission to lower acuity care units may reduce costs without compromising care.

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“…Our reabstraction methodology did not permit us to measure the sensitivity of our proposed coding algorithms; however, our analysis yielded similar PPV optimizing code combinations for the identification of eOSR and eEVAR repairs, presumably retaining the sensitivity benefits of these combinations demonstrated by Jetty et al In contrast, we did not use anesthesia modifiers to help further refine our algorithms. Although eEVARs can be conducted under local or regional anesthesia, general anesthesia is used for EVAR in approximately 90% of cases, according to a large Vascular Quality Initiative study [28]. This is likely attributable to conflicting reports regarding the superior safety of loco-regional anesthetic techniques for EVAR [29,30].…”

Section: Discussionmentioning

confidence: 99%

Validation of abdominal aortic aneurysm repair codes in Ontario administrative data

Salata

Hussain

Mestral

et al. 2018

CIM

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Purpose: To determine the positive predictive values (PPV) of Ontario administrative data codes for the identification of open (OSR) and endovascular (EVAR) repairs of elective (eAAA) and ruptured (rAAA) abdominal aortic aneurysms. Methods: We randomly identified 319 eAAA and rAAA repairs at two Toronto hospitals between April 2003 and March 2015, using administrative health data in Ontario, Canada. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes I71.3 and I71.4, were used to identify rAAA and eAAA patients, respectively. A blinded retrospective chart review was conducted and served as the gold standard comparator. Re-abstracted records were compared to Canadian Classification of Health Interventions (CCI) and Ontario Health Insurance Plan (OHIP) codes in the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) and OHIP databases. We calculated the PPV and 95% confidence intervals (95% CI) of individual and combined procedure and billing codes for elective and ruptured OSR and EVAR (eOSR, eEVAR, rOSR, and rEVAR). Results: Permutation of codes allowed identification of eOSR with 95% PPV (95% CI 88, 98), eEVAR with 96% PPV (95% CI 90, 99), rOSR with 87% PPV (95% CI 79, 93) and rEVAR with 91% PPV (95% CI 59, 100). Conclusions: Diagnostic, procedure and billing code combinations allow identification of eOSR, eEVAR, rOSR and rEVAR patients in Ontario administrative data with a high degree of certainty.

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Local anesthesia for percutaneous endovascular abdominal aortic aneurysm repair is associated with fewer pulmonary complications

Abstract: Although it was used in only 1 in 10 cases of percutaneous EVAR, LA was associated with fewer pulmonary complications after adjustment for patient factors. Surgeons should consider expanding the use of LA for percutaneous EVAR when feasible.

Cited by 32 publications

References 21 publications

Type of Anesthesia for Endovascular Abdominal Aortic Aneurysm Repair

Type of Anesthesia for Endovascular Abdominal Aortic Aneurysm Repair

Perioperative Outcomes for Centers Routinely Admitting Postoperative Endovascular Aortic Aneurysm Repair to the ICU

Validation of abdominal aortic aneurysm repair codes in Ontario administrative data

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