Retroperitoneal approach used exclusively with epidural anesthesia for infrarenal aortic disease

Rosenbaum, Gary J.; Arroyo, Pedro J.; Sivina, Manuel

doi:10.1016/s0002-9610(94)80053-7

Cited by 11 publications

(3 citation statements)

References 19 publications

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“…Rosenbaum et al in 1994 reported a case series of 69 patients using the RP under epidural anesthesia for occlusive infrarenal aortoiliac disease. 6 They reported a mortality rate of 1.6% and major morbidity rate of 11%. No pulmonary complications were reported which the authors ascribe to the absence of endotracheal intubation.…”

Section: Discussionmentioning

confidence: 98%

Open Abdominal Aortic Aneurysm Replacement in the Awake Patient

et al. 2015

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We report a case of open replacement of an abdominal aortic aneurysm (AAA) under regional anesthesia alone. The potential benefits of the procedure are presented. Case ReportA 78-year-old man was found to have an asymptomatic 5.1-cm diameter AAA during investigation of hematuria for which no cause was ascertained. His medical history included type II diabetes mellitus, hypertension, vertebrobasilar insufficiency, cerebrovascular event, and emphysema. He was independent in daily living activities and had smoked daily for the past 60 years. Following initial assessment, he was enlisted in our ultrasound AAA surveillance program.Overall, 10 months from initial diagnosis, his aneurysm had increased in size to 5.6 cm diameter with a short dissection flap extending from the neck to the origin of the left common iliac artery (CIA) as defined by CT angiography. Two marked neck angulations were present, the most proximal measuring 58 degrees (►Fig. 1) and the second 71 degrees (►Fig. 2). Neck length was 30 mm and diameter was 19 mm. As such aneurysm neck angulations precluded endovascular stent grafting (endovascular aneurysm repair [EVAR]), he underwent preoperative anesthetic assessment of his suitability for open repair.The assessment included a full blood count, renal and coagulation profiles, and electrocardiogram, which were all within normal parameters. Echocardiography revealed normal left ventricular function with mild diastolic impairment. A chest radiograph showed gross emphysematous changes with an enormous bulla at the left lung base as confirmed by CT scan. Lung function tests revealed a forced expiratory volume over 1 second (FEV 1 ) of 1.0 L (36%) predicted and a forced vital capacity (FVC) of 2.56 L (70% predicted) (FEV 1 : FVC ¼ 53). FEF 25 to 75/FVC ¼ 16% predicted values. He described his exercise limit as being able to walk 100 yards on the flat and cardiopulmonary exercise testing demonstrated an anaerobic threshold of 12.7 mL/kg/min.In view of his poor respiratory function and in the face of particular concerns over intraoperative bullous rupture during positive pressure ventilation, it was felt that, because of an excessive perioperative risk, an open procedure would be performed under combined spinal and thoracic epidural anesthesia with bilateral transverses abdominis plane blocks, supplemented with intravenous sedation. No tracheal intubation or inhalation agents were used. A retroperitoneal approach Keywords ► abdominal aortic aneurysm ► epidural anesthesia ► regional anesthesia AbstractNonintubated aortic surgery using various techniques has been reported, but despite publication of favorable outcomes in select patient groups, awake aortic surgery remains unpopular. Our patient had an abdominal aortic aneurysm that was unsuitable for endovascular repair. Because of the significant respiratory disease, general anesthesia represented an unacceptably high risk. As a result, he underwent open AAA repair via a retroperitoneal approach with the aid of epidural anesthesia. Here, we highlight the ben...

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Section: Discussionmentioning

confidence: 98%

Open Abdominal Aortic Aneurysm Replacement in the Awake Patient

et al. 2015

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“…Patients were not heterogeneous in term of surgical risk and comorbidities. A bigger case series has been presented by Rosenbaum et al [5]. in 1994 with 62 patients operated of infrarenal aortic disease via retroperitoneal approach with lumbar epidural anesthesia alone.…”

Section: Discussionmentioning

confidence: 99%

Open Conversion Abdominal Aortic Endograft in Thoracic Epidural Anesthesia alone in Patient with Severe COPD: A Case Report of Surgery in awake Patient and Review of the Literature

et al. 2023

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A 79-year-old male was referred, with open abdomen surgical indication, for an asymptomatic iuxtarenal abdominal aortic aneurysm and type I endoleak with distal migration of an endovascular aortic – bisiliac prosthesis, after an endovascular correction done eight years before. This patient has several comorbidities such severe COPD (Stage IV and oxygen dependent), chronic kidney disease (G4 KDIGO CKD classification), systemic arterial hypertension and severe peripheral vasculopathy. Spirometry gives a picture of severe obstruction: FVC 2,44 L (68%), FEV1 0,68 L (25%), TLC 7.72 L (118%), RV 4,88 L (181%). 3 L/min oxygen arterial blood gas was: pH 7,34, PaO2 74,9 mmHg, PaCO2 51,2 mmHg, HCO3- 24,3 mEq/L, BE – 0,2, SpO2 94,2%. Cardiological consultation did not found any problem (normal ejection fraction, no valvular pathologies, and no pulmonary hypertension). Vascular echography highlighted an aortic aneurysm, confirmed by computed tomography angiography: iuxtarenal abdominal aortic aneurysm of 68 mm × 72 mm extended for 70 mm (Figure 1). According to the European Society of Anesthesiologists guidelines [1,2], general anesthesia is not safe, because of the elevated perioperative risks of severe respiratory complications. After a collegial respiratory risk evaluation, we have decided for an awake surgery with an epidural anesthesia. Operative risks were assessed with the patient who accepted intervention.

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“…34,35 Many clinicians use an epidural catheter for intraoperative anesthesia and postoperative pain management. Epidural anesthesia has been used as the sole anesthetic for infrarenal surgery performed through the retroperitoneal approach.…”

Section: Anesthetic Technique and Intraoperative Managementmentioning

confidence: 99%