Local versus General Anesthesia for Thoracic Endovascular Aortic Repair in Patients with Acute Type B Dissection
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0192
Submission Type:
Abstract Submission
Authors:
Wei-Guo Ma (1), Song Chen (2), Wen-Jing Guo (2), Tong-Xuan Wang (3), Zhi-Liang Song (3), Yang Liu (3), Xing-Peng Chen (2)
Institutions:
(1) Yale New Haven Hospital, Connecticut, (2) Luoyang Central Hospital, Luoyang, NA, (3) Luoyang Central Hospital, Luoyang, China
Submitting Author:
Wei-Guo Ma
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Yale New Haven Hospital
Yale New Haven Hospital
Co-Author(s):
Song Chen
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Luoyang Central Hospital
Luoyang Central Hospital
Wen-Jing Guo
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Luoyang Central Hospital
Luoyang Central Hospital
Tong-Xuan Wang
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Luoyang Central Hospital
Luoyang Central Hospital
Zhi-Liang Song
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Luoyang Central Hospital
Luoyang Central Hospital
Yang Liu
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Luoyang Central Hospital
Luoyang Central Hospital
Xing-Peng Chen
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Luoyang Central Hospital
Luoyang Central Hospital
Presenting Author:
Wei-Guo Ma
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Yale New Haven Hospital
Yale New Haven Hospital
Abstract:
Objective: To compare the early and late outcomes of thoracic endovascular aortic repair (TEVAR) under local anesthesia (LA) vs general anesthesia (GA) in acute type B dissection (ATBAD).
Methods: Of 247 patients (mean age 52.9±12.6 years; 195 men [78.9%]) receiving TEVAR for ABTAD from 2016-2021, 44 underwent GA and 203 received LA (lidocaine infiltration + dexmedetomidine sedation + butorphanol analgesia). Two groups were compared in respect to intraprocedural and early and late outcomes. Risk factors were identified for all-cause death and late adverse events (a composite of endoleak, retrograde type A dissection [RTAD], and distal aortic dilation).
Results: Baseline and pre-anesthesia data were comparable between 2 groups. At anesthesia start, LA group showed higher systolic blood pressure (SBP) (134 vs 123 mmHg, P<.001) and diastolic BP (DBP) (76 vs 72 mmHg, P=.044) and faster heart rate (HR) (77 vs 73 bpm, P=.026). During anesthesia, HR (74 vs 71 bpm, P=.186) and SBP (123 vs 119 mmHg) were similar between 2 groups, while LA group showed higher DBP (69 vs 65, P=.024). Technical success was 100%. The stent graft was 19 cm long and 33 mm in diameter, covering 3-5 zones in 58 (23.5%) and ≤2 zones in 189 patients (76.5%), similar between LA and GA. Upon anesthesia completion, LA group had a visual analog scale of 1.2±0.4 and Ramsay sedation scale of 3.2±0.5 (Table). Compared to GA group, LA group showed significantly shorter anesthesia (84 vs 136 min, P=.001) and procedure times (66 vs 115 min, P=.002), and less blood loss (20 vs 53 mL, P<.001) and fluid infusion (515 vs 1032 mL, P<.001).
Ten endoleaks (4%) were detected intraoperatively, including type I in 9 and type II in 1. Complications included stroke in 3 patients (1.2%), spinal cord ischemia in 2 (0.8%), acute kidney injury in 2 (0.8%) and limb ischemia in 4 (1.6%). In LA group, 2 patients underwent reintervention (0.8%) for access site injury, and 1 required exploratory laparostomy for visceral trauma. Despite similar morbidities in 2 groups (all P>.05), early mortality was significantly lower in LA group (1% [2/203] vs 6.8% [3/44], P=.041), who also had shorter lengths of ICU (3 vs 31 hours, P=.001) and hospital stay (23 vs 28 days, P=.040).
Follow-up was 100% complete (242/242) at mean 3.2±1.8 years. Ten patients died at 2.0±1.3 years, distal aortic dilation occurred in 11 at mean 2.6±0.9 years, endoleak in 4 at 2.0±0.6 years, and RTAD in 4 at 3.0±1.6 years, all similar between 2 groups. Reoperation was done in 5 patients at 2.6±1.5 years for RTAD in 4 and proximal aortic ulcer in 1, which was more common in LA group (1.6% vs 7.3%, P=.035). Despite similar survival at 5 years (93.6% vs 87.9%, P=.125), freedom from late adverse events (LAE) was significantly higher in the LA group (89% vs 62.4%, P=.015).
In Cox regression, 3-5 zones covered (vs ≤2) was a predictor of all-cause death (hazard ratio [HR] 3.54; 95% confidence interval [CI] 1.24-10.13, P=.018) and LAE (HR 2.96; 95% CI 1.03-8.52; P=.044), while LA was associated lower risk of LAE (HR 0.24; 95% CI 0.09-0.66; P=.005).
Conclusion: In this series of TEVAR for ATBAD, LA has achieved less physiological disturbance and blood loss, shorter anesthesia and procedure times, lower early mortality, shorter length of ICU and hospital stay, and fewer late reinterventions and adverse events compared to GA. These results argue favorably for more frequent use of local anesthesia in TEVAR for patients with ATBAD.
Methods: Of 247 patients (mean age 52.9±12.6 years; 195 men [78.9%]) receiving TEVAR for ABTAD from 2016-2021, 44 underwent GA and 203 received LA (lidocaine infiltration + dexmedetomidine sedation + butorphanol analgesia). Two groups were compared in respect to intraprocedural and early and late outcomes. Risk factors were identified for all-cause death and late adverse events (a composite of endoleak, retrograde type A dissection [RTAD], and distal aortic dilation).
Results: Baseline and pre-anesthesia data were comparable between 2 groups. At anesthesia start, LA group showed higher systolic blood pressure (SBP) (134 vs 123 mmHg, P<.001) and diastolic BP (DBP) (76 vs 72 mmHg, P=.044) and faster heart rate (HR) (77 vs 73 bpm, P=.026). During anesthesia, HR (74 vs 71 bpm, P=.186) and SBP (123 vs 119 mmHg) were similar between 2 groups, while LA group showed higher DBP (69 vs 65, P=.024). Technical success was 100%. The stent graft was 19 cm long and 33 mm in diameter, covering 3-5 zones in 58 (23.5%) and ≤2 zones in 189 patients (76.5%), similar between LA and GA. Upon anesthesia completion, LA group had a visual analog scale of 1.2±0.4 and Ramsay sedation scale of 3.2±0.5 (Table). Compared to GA group, LA group showed significantly shorter anesthesia (84 vs 136 min, P=.001) and procedure times (66 vs 115 min, P=.002), and less blood loss (20 vs 53 mL, P<.001) and fluid infusion (515 vs 1032 mL, P<.001).
Ten endoleaks (4%) were detected intraoperatively, including type I in 9 and type II in 1. Complications included stroke in 3 patients (1.2%), spinal cord ischemia in 2 (0.8%), acute kidney injury in 2 (0.8%) and limb ischemia in 4 (1.6%). In LA group, 2 patients underwent reintervention (0.8%) for access site injury, and 1 required exploratory laparostomy for visceral trauma. Despite similar morbidities in 2 groups (all P>.05), early mortality was significantly lower in LA group (1% [2/203] vs 6.8% [3/44], P=.041), who also had shorter lengths of ICU (3 vs 31 hours, P=.001) and hospital stay (23 vs 28 days, P=.040).
Follow-up was 100% complete (242/242) at mean 3.2±1.8 years. Ten patients died at 2.0±1.3 years, distal aortic dilation occurred in 11 at mean 2.6±0.9 years, endoleak in 4 at 2.0±0.6 years, and RTAD in 4 at 3.0±1.6 years, all similar between 2 groups. Reoperation was done in 5 patients at 2.6±1.5 years for RTAD in 4 and proximal aortic ulcer in 1, which was more common in LA group (1.6% vs 7.3%, P=.035). Despite similar survival at 5 years (93.6% vs 87.9%, P=.125), freedom from late adverse events (LAE) was significantly higher in the LA group (89% vs 62.4%, P=.015).
In Cox regression, 3-5 zones covered (vs ≤2) was a predictor of all-cause death (hazard ratio [HR] 3.54; 95% confidence interval [CI] 1.24-10.13, P=.018) and LAE (HR 2.96; 95% CI 1.03-8.52; P=.044), while LA was associated lower risk of LAE (HR 0.24; 95% CI 0.09-0.66; P=.005).
Conclusion: In this series of TEVAR for ATBAD, LA has achieved less physiological disturbance and blood loss, shorter anesthesia and procedure times, lower early mortality, shorter length of ICU and hospital stay, and fewer late reinterventions and adverse events compared to GA. These results argue favorably for more frequent use of local anesthesia in TEVAR for patients with ATBAD.
Aortic Symposium:
Anesthesia and Perioperative Management
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