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Puskas, Ference, MD, PhDEVAR and TEVAR - Anesthetic PerspectiveObjectivesEVAR and TEVAR –AnestheticPerspectiveF E RE N C P US K A S , M D, P H DAbbreviationsoTAAA: Thoracoabdominal aortic aneurysmoSCI: Spinal cord injuryoER and SR: Endovascular and Surgical RepairoEVAR: Endovascular aneurysm repair for AAAtreatmentoTEVAR: Thoracic endovascular aneurysm repairClassification of Aortic Dissection Understand when to worry about spinal cordischemia and what can we do about it Develop a protocol for the most appropriatemanagement of a patient undergoing TEVAR Discuss risks vs. benefits of general anesthesiavs. regional anesthesia vs. local anesthesia withsedation for EVARHistorical Perspective 1953, Debakey and Cooley: first successful resectionof TAAA 1990s endovascular stents pioneered 2005 FDA approves TEV(A)R for aneurysm stenting September 13, 2013, FDA approves the GORE,January 28, 2014, the Medtronic Valiantendovascular stent system for type B dissectiontreatmentCrawford Classification of TAAAs Extent 0. Extent I. Extent II. Extent III. Extent IV.Coselli et al. The Annals Thorac Surgery, Vol 83, 2, S862-S864, 2007

Puskas, Ference, MD, PhDEVAR and TEVAR - Anesthetic PerspectiveExtent DefinitionTypeDefinition0Distal to LCA to abovediaphragm1Distal to LCA beyond diaphragm,above renal2Distal to LCA, below renalarteries3Distal 6th intercostal space,below renal arteries4Below diphragm to below renalarteriesSCI after 2286 Open TAAAsDoes endovascularsurgery decreases therisk of spinal cord injury?Medtronic thoracic endovascular registry Aka MOTHER databaseExtent ofrepairPatients (n)30-daysurvival, n(%)Paraplegia/Paraparesisn (%)Renal Failure,n (%)I.706671 (95.0)23 (3.3)19 (2.7)II.762716 (94.0)48 (6.3)63 (8.3)III.391370 (94.6)10 (2.6)24 (6.1)IV.427414 (97.0)6 (1.4)23 (5.4)Total22862171 (95.0)87 (3.8)129 (5.6) From 5 prospective studies 1010 patients 670 thoracic aortic aneurysm 195 chronic type B dissection 114 acute type B dissectionCoselli et al. The Annals Thoracic Surgery, Vol 83, 2, S862-S864, 2007Cleveland Clinic Comparison of Endo (ER)versus Surgical (SR) RepairSCI outcomeElectiveThoracic Aneurysm(n 625)Chronic Type B(n 179) Roy Greenberg et al.Spinal Cord Injury, n(%)30 (5)6 (3) Consecutive cohort of patients between 2001 to2006Non-electiveThoracic Aneurysm(n 38)Chronic Type B(n 15)Acute Type B (n 114)Spinal Cord Injury,n(%)5 (11)0 (0)2 (2)ParaplegiaParaparesisResolution152712Spinal Cord Injury(n 42) Treated electivelyPatterson B. et al. Circulation 127:24-32, 2013. 724 patients (352 ER v. 372 SR)

Puskas, Ference, MD, PhDEVAR and TEVAR - Anesthetic PerspectiveSCI by Extent of Aneurysmal DiseasesExtentNoneI.II.III.IV.AllRepairnSCI nSCI SR62610ER6923SR6412ER352154SR372288Author’s Conclusions Extent to extent the risk ofSCI between ER versus SRis not significantly different The most important factoris the extent of disease andrequired repair procedureoExtent II. being thehighest risk TEVAR patients tend to besicker Prior distal aortic repairpreceding ER, increasesrisk of SCI (compromisediliac circulation) Patients with SCI are morelikely to dieCirculation, Volume 118(8):808‐817, August 19, 2008Author’s Conclusions SCI is more likely to manifest early after SR SCI after ER is characterized by a ‘delayed’manner and associated with postoperativehypotension:o delayed: the appearance of paraparesis orparaplegia in 24 to 48 hoursIn addition, clinical experience andresearch have shown us that the mosteffective approach to decrease spinalcord injury is to thoroughly understandthe spinal cord circulation and itsresponse to arterial occlusionThus understanding the type andplanned anatomical extent ofaortic surgery is critical inassessing the risk of SCITA K E H O M E M E S S AG ESpinal cord bloodsupplyTWO MAJOR ARTERI ES AND THE COLLA TERALS

Puskas, Ference, MD, PhDEVAR and TEVAR - Anesthetic PerspectiveImportant conceptsSpinal Cord Collaterals 2 major arteriesoSubclavian arteryoHypogastric artery (internal iliac) Segmental Arterial NetworkoOnly 6 to 8 segmental feeder rom the aorta,penetrate the dura, mostly from the leftoExtensive collaterals (paraspinal muscles)Bischoff MS et al. Perspectives in Vascular Surgery and Endovascular Therapy 23 (3) 214‐222, 2011Number of clamped SA before MEP lossSpinal or CSF drain Initial CSF pressure usually 12‐20 mmHg Recommendation is to drain CSF to 10 ‐12mmHg Traditional teaching: SCP MAP‐CSFP Does decreasing CSF pressure by 5 ‐ 10 mmHgreally has a significant effect on spinal cordperfusion?Bischoff MS et al. Perspectives in Vascular Surgery and Endovascular Therapy 23 (3) 214‐222, 2011Direct Spinal Cord Perfusion Pressure Monitoringin Extent 2 Aortic Aneurysm Repair Randall B. Griepp, MD Ann Thoracic Surg, 2009;87:1764 Mount Sinai, Cardiothoracic Surg 13 patients had SA pressure directly monitored Intraoperatively and up to 48 hrs

Puskas, Ference, MD, PhDEVAR and TEVAR - Anesthetic PerspectiveCollateral Network Pressure (CNP)Recommendations for Spinal Cord Protection 75 % of mean arterial pressure at baseline It falls variably with X‐clamp down to 20 – 40 mmHg True spinal cord perfusion pressure?oSCPP CNP – CSF (or CVP) pressureoDecreasing CSF pressure from 12‐20 down to 10mmHg does have a significant perfusion effectOpen and endovascular thoracic aortic repair with highrisk for spinal cord ischemic injury (Class I)2010 Guidelines for the Diagnosis and Management of patients withthoracic aortic disease. Circulation, 2010; 121:e266‐e369Bischoff MS et al. Perspectives in Vascular Surgery and Endovascular Therapy 23 (3) 214‐222, 2011.High Risk for SCIEndovascular RepairLowers SCI risk Emergent Surgery Perioperative Hypotension CSF drain for Extent 2 or High Risk repairso 10mmHg CSF pressure and CVP Extent II. coverage Distal aortic perfusion (SR) Subclavian coverage without revascularization Previous distal aortic surgeryo Iliac artery perfusion (SR and ER) MAP 90 mmHg Iliac artery injuryoDistal spinal cord perfusion Staged procedureoMaintaining subclavian patencyoAvoid Iliac injury!!!Spinal cord protection protocolTEVAR Anesthetic Protocol Place CSF drain the day beforesurgery If SSEP signal decrease drain 10 ml Always a GA MAP 90 hgmm post‐surgery Record opening pressure, zero toRA Assess risk of SCI Clamp drain after confirmingbilateral lower extremity function If pressure exceeds 12 mmHg,pressure goal 10mmHg Remove drain after 24 hrs ofclamping Limit CSF drain to less than 20 mlover 1st‐hr Reopen/Drain if delayedparaparesis/paraplegia Two 16G IVs Limit CSF drain to less than 40 mlover 4‐hours If CSF turns bloody turn off drain,consider, CT or MRI Let the MAP run up after stent placement Consider spinal drain And neuromonitoring Arterial line TEE (risk of retrograde dissection, risk 1.33%)

Puskas, Ference, MD, PhDEVAR and TEVAR - Anesthetic PerspectiveRetrograde Dissection after Type BDissection Stenting and its mortalityWhat about EVARS?Eggebrecht H et al. Circulation. 2009;120:S276‐S281Choice of Anesthetic No prospective randomized controlled trial None of the outcome studies consideredanesthesia to be a factorWhy? Evidence from retrospective andobservational studiesTO P UT A TUB E A N D A CO UP LE O F I V S ? ? ?Anesthetic techniques for EVAR General Anesthesia Regional Anesthesia (epidural alone orspinal or combined) Local Anesthesia (local groin infiltration)with sedationRisk‐adapted Outcome after Endovascular AorticAneurysm Repair: Analysis of Anesthesia TypesBased on EUROSTAR data Ruppert et al. Journal of Endovascular Therapy, 14 (1),2007. 1997 and 2004, 164 centers, 5557 patients Patients were divided into low‐risk (ASA I or II.), high‐risk (ASA III or IV), LA, GA, RA into 6 groups. Low‐risk group: 78.8% GA, 15.9% had RA, 5.3% LA High‐risk group: 60.4 % GA, 33.7% RA, 5.9% LA

Puskas, Ference, MD, PhDEVAR and TEVAR - Anesthetic PerspectiveLocoregional anesthesia for endovascularaneurysm repairOutcomes GA vs. RA or LA: less systemiccomplications (cardiac,cerebral, pulmonary, renal,hepatobiliary, sepsis) J Vasc Surgery 2012;56:510‐9 Ten studies, 13,459 patient received local or general anesthesia No difference in 30 days mortality GA versus RA: less 30 days earlydeath in the RA group Less ICU admission with localand regional (low risk and highrisk) LA patients are older and sicker, shorter hospital stay, fewerpostoperative /1.29.0%3.6%Observation from the IMPROVE trial Trial concerning the clinical care of patients with ruptured abdominalaortic aneurysms (BJS 2014; 101:216‐224) Prospective multicenter, mostly UK, observationalGA RA LAS H O RT TERM O UTC O M E S Anesthesia type on the discretion of the care team 558 with a symptomatic or ruptured aneurysm Lowest blood pressure ( 70 Systolic) was strongly and independentlyassociated with 30‐days mortality (51 versus 34.1) EVAR with local anesthesia (adjusted to variables) alone had greatlyreduced (4 fold) 30 days mortalityTA K E H O M E M E S S AG EAJAX trialAJAX trial Primary outcome: Death and severe complications Secondary outcomes: Morbidity 116 patients randomized 26 of 57 patient EVAR was started with local, 13 of themwere converted to general (5 converted to open repair,8 discomfort)

Puskas, Ference, MD, PhDEVAR and TEVAR - Anesthetic PerspectiveAJAX trialAJAX trial Death and severe complications at 30 days: The low open repair mortality was very surprising: EVAR: 42% Open repair: 47 % (N.S.) 30 days mortality EVAR: 21% Open: 25% (N.S.) Occurred less often in the EVAR group: renal insufficiency 65% expected, 47% actual Introduction of round‐the‐clock aneurysm service Centralization of care Routine preoperative CTA Average open repair OR time: 157 min Surgery time: 125 min EBL: 3500 mlCost of EVAR Mean cost difference between EVAR and open repair: 30 days: 5306 euro 6 months: 10189 euro Cost effectiveness ratio per prevented death at 6 month: 424,542 euro No benefit in Quality of LifeEVAR Anesthetic Plan Do not need Cardiac Anesthesia Local for emergent until rupture is controlled Keep MAP 70 LA RA GA Arterial line Couple of big IVs ‘Outpatient EVARS’Limitations to Local or Regional Pre‐existing anticoagulation ‐ unable tobridge Obesity OSA Patient compliance Potential need for iliac accessStent migration andBP?W H AT S H O UL D B E T H E B LO O D P RE S S U RE B E ATD E P LOY M E N T ?

Puskas, Ference, MD, PhDEVAR and TEVAR - Anesthetic PerspectiveThank you!Final session of the Cardiac block. Case presentations Quick Question: Preload (volume) management , General Anesthesia cases in patients with RVdysfunction? Hypertrophied or dilated RV, with PS and PI? With or without pulmonary hypertension? Limit fluids? Use inotropes first? Give fluids, inotropes second? How about phenylephrine?

Anesthesia type on the discretion of the care team 558 with a symptomatic or ruptured aneurysm Lowest blood pressure ( 70 Systolic) was strongly and independently associated with 30‐days mortality (51 versus 34.1) EVAR with local anesthesia (adjusted to variables) alone had greatly