SEARCH

SEARCH BY CITATION

Summary

  1. Top of page
  2. Summary
  3. Overview of vascular emergencies
  4. Endovascular management
  5. Anaesthetic management of vascular emergencies
  6. Strategies to reduce morbidity
  7. Postoperative management
  8. Acknowledgements
  9. Competing interests
  10. References

Patients presenting with vascular emergencies including acute aortic syndrome, ruptured thoracic or abdominal aortic aneurysms, thoracic aortic trauma and acute lower limb ischaemia have a high risk of peri-operative morbidity and mortality. Although anatomical suitability is not universal, endovascular surgery may improve mortality and the results of ongoing randomised controlled trials are awaited. Permissive hypotension pre-operatively should be the standard of care with the systolic blood pressure kept to 50–100 mmHg as long as consciousness is maintained. The benefit of local anaesthesia over general anaesthesia is not definitive and this decision should be tailored for a given patient and circumstance. Cerebrospinal fluid drainage for prevention of paraplegia is often impractical in the emergency setting and is not backed by strong evidence; however, it should be considered postoperatively if symptoms develop. We discuss the pertinent anaesthetic issues when a patient presents with a vascular emergency and the impact that endovascular repair has on anaesthetic management.

In-hospital mortality after open repair of ruptured abdominal aortic aneurysm (rAAA) approaches 40–50% with total mortality, including pre-hospital deaths, closer to 80% [1–3]. Traumatic thoracic aortic injury is often immediately fatal with a 30–40% mortality in those who arrive alive to hospital and an overall mortality of 90% [4]. Thirty-day mortality rates are  > 50% following ruptured thoracic aneurysm [5], 13% for acute type B dissection [6] and > 25% following embolectomy for acute limb ischaemia [7, 8].

We define a ‘vascular emergency’, for the purpose of this review, as an acute condition requiring intervention within hours, involving the descending aorta and its main lower limb branches. Specific pathologies meeting these criteria include acute aortic syndrome, ruptured thoracic and abdominal aneurysms, traumatic injuries of the thoracic aorta and acute lower limb ischaemia. Pathology involving the ascending aorta or aortic arch that is generally managed by cardiac surgeons is excluded.

This review aims to discuss the optimal anaesthetic management to minimise morbidity and mortality and the impact of a move towards endovascular repair. An English language electronic search using Medline and Embase databases identified relevant scientific literature from the last 10 years and was supplemented with a manual search of reference lists from reviewed articles.

Overview of vascular emergencies

  1. Top of page
  2. Summary
  3. Overview of vascular emergencies
  4. Endovascular management
  5. Anaesthetic management of vascular emergencies
  6. Strategies to reduce morbidity
  7. Postoperative management
  8. Acknowledgements
  9. Competing interests
  10. References

Acute aortic syndrome

Acute aortic syndrome consists of three interrelated conditions: penetrating atherosclerotic ulcer; intramural haematoma; and aortic dissection. Penetrating atherosclerotic ulcers and intramural haematoma are treated as for type-B dissections with the usual caveats for surgical intervention [9]. Aortic dissection occurs when an intimal tear allows blood under pressure to separate the layers of the aorta. The result is a ‘true lumen’ and ‘false lumen’ separated by a dissection flap. The Stanford classification defines dissection along treatment lines. Type A dissections (∼60%) involve the ascending aorta, proceed to emergency surgery and are not discussed in this review. Type B dissections (∼40%) are limited to the descending aorta or aortic arch and emergency surgery is considered for those with end-organ ischaemia, intractable pain, uncontrollable blood pressure or rupture [9].

image

Figure 1. Crawford classification of thoraco-abdominal aortic aneurysms.

Download figure to PowerPoint

Ruptured thoraco-abdominal aortic aneurysm (rTAAA)

The Crawford classification of rTAAA is based on the extent of aortic involvement (Fig. 1) that affects both the intra-operative and postoperative course. Emergency surgery for thoraco-abdominal aortic aneurysms is generally reserved for cases of rupture.

Thoracic aortic trauma

Thoracic aortic trauma often occurs during a motor vehicle accident, as sudden deceleration results in movement of the relatively mobile aortic arch on the descending aorta, in the peri-isthmic region (Fig. 2). Polytrauma in this setting adds controversy to the timing of repair – on the one hand expeditious surgery minimises the risk of rupture; however, systemic heparinisation, aortic cross clamp and lateral positioning can exacerbate co-existing injuries. Alternatively, delaying repair until other injuries are stable risks aortic rupture and controlled hypotension in the interim can have deleterious consequences, especially in patients with co-existing head injury. Growing interest in early endovascular treatment shows evidence of improved outcomes with this approach [10].

image

Figure 2.  Important landmarks of the aorta and branches of the left subclavian artery.

Download figure to PowerPoint

Ruptured abdominal aortic aneurysm

Most patients with rAAA who reach hospital alive have a contained retroperitoneal haematoma with tamponade effect. Immediate death usually results from free intra-peritoneal rupture [1, 11, 12]. Open operations on the abdominal aorta proceed through a midline laparotomy.

Acute lower limb ischaemia

Acute limb ischaemia is characterised by a pale, pulseless, paralysed, parasthetic and/or painful limb. Most commonly the cause is embolic or thrombotic [13, 14]. The Rutherford classification [15] (Fig. 1) provides a common language when discussing severity of acute and chronic limb ischaemia. Acute limb ischaemia is distinct from ‘critical limb ischaemia’, a severe form of chronic ischaemia that includes gangrene and rest pain. Restoration of flow in an acutely ischaemic limb can be attempted by surgical revascularisation (embolectomy, endarterectomy or bypass grafts) or pharmacological dissolution of thrombus [14, 16]. Fasciotomy (if there are signs of compartment syndrome) or even amputation may be necessary.

Endovascular management

  1. Top of page
  2. Summary
  3. Overview of vascular emergencies
  4. Endovascular management
  5. Anaesthetic management of vascular emergencies
  6. Strategies to reduce morbidity
  7. Postoperative management
  8. Acknowledgements
  9. Competing interests
  10. References

Overview

Endovascular aortic reconstruction (EVAR), first reported in 1991 [17], was quickly adopted for patients with leaking [18] and rAAAs [19]. A completely percutaneous modification (avoiding arteriotomy) has been reported in the acute setting [20]. An aorto-uni-iliac device is easier and quicker to deploy and requires only one suitable iliac artery [21]; however, it does necessitate a femoro-femoral bypass graft to provide contralateral lower extremity blood flow.

Thoracic endovascular aortic reconstruction (TEVAR) produces additional considerations. Stent coverage of the left subclavian artery, which supplies antegrade flow to the ipsilateral arm and left vertebral artery (Fig. 2), may be problematic. If the left subclavian artery is covered, the left arm receives retrograde flow from the left vertebral artery potentially resulting in a steal phenomenon [22] characterised by dizziness and visual changes. Patients with a left internal thoracic artery (LITA) to coronary artery bypass graft may suffer myocardial ischaemia as the LITA comes off the left subclavian artery. If the proximal landing zone necessitates coverage of the left subclavian artery, revascularisation should be considered using, for example, a carotid to left subclavian artery graft [22]. Temporary apnoea and hypotension may be required to ensure precise positioning of the graft. Asystole induced by adenosine or rapid transvenous pacing were previously required, but modern self-expanding stents require only a modest drop in blood pressure, which can be achieved with a bolus of propofol, nitroglycerine or esmolol.

Rapid control techniques

Some authors strongly recommend a ‘clamp before you cut’ approach [23] using a transfemoral aortic occlusion balloon before laparotomy to reduce the haemodynamic disturbance following release of abdominal wall tamponade. In a small series, Philipsen et al. demonstrated that by transferring unstable patients with rAAA directly to the operating room and placing an aortic occlusion balloon under local anaesthesia, they could then assess suitability for EVAR using angiography. Overall 30-day mortality was only 17% despite significant pre-operative instability [24].

Suitability for EVAR

Approximately, 40–50% of patients with rAAA have suitable anatomy for endovascular repair [25, 26]. Adequate proximal and distal landing zones and appropriately sized groin access vessels are required. Although transporting a potentially unstable patient presents some risk, a pre-operative CT helps determine suitability. Lloyd et al. performed a ‘time to death’ study in patients with rAAA who reached hospital alive but did not undergo surgery for various reasons. They reported that 87.5% of patients survived more than two hours which is usually sufficient time to undertake a CT scan [27]. Endovascular stenting is less desirable in patients with Marfan’s syndrome and other connective tissue disorders as long-term durability in this subset of patients is uncertain [28].

Is endovascular surgery the answer to reducing mortality?

In an elective setting, three randomised trials compared EVAR with open AAA repair, showing an early mortality benefit for EVAR [29–31] that was not sustained at 2 to 4-year follow-up [31–33]. Following aortic rupture, endovascular surgery has shown promise in reducing mortality. Mortality rates following EVAR for rAAA are less than 20% in several non-randomised studies [1, 21, 34–37] and 17–30.2% in other large meta-analyses [2, 38–41]. However, randomised controlled trial (RCT) data are currently lacking. The only prospective RCT to date was terminated early, published as a pilot study and showed no difference in 30-day mortality [42]. Three RCTS are currently underway – the AJAX trial, ECAR trial [43] and the multicentre IMPROVE trial; all are yet to publish their results.

For thoracic aortic emergencies, an endovascular approach shows favourable outcomes in non-randomised studies [44–47]. For uncomplicated aortic dissection, medical management is traditionally preferred; however, long-term outcomes are poor, with 5-year mortality approaching 50% [28]. This tradition may be challenged with improved outcomes for endovascular treatment. Xu et al. used TEVAR in 63 patients with acute type B dissections, and showed a 30-day mortality of 3.2% and 4-year survival of 89.4% [48].

A mortality benefit not withstanding, EVAR avoids aortic cross clamping and abdominal incision, allows proximal control without general anaesthesia [49], and shows reductions in procedure time, blood loss, intensive care unit (ICU) and hospital stay [35, 38, 50]. EVAR for thoracic emergencies avoids the need for a high aortic cross clamp and one lung ventilation.

There are certain complications specific to endovascular repair including graft malpositioning, iliac artery rupture and retrograde conversion of a type B dissection to a type A dissection [9, 48]. Endoleaks and postimplantation syndrome cause postoperative morbidity.

Anaesthetic management of vascular emergencies

  1. Top of page
  2. Summary
  3. Overview of vascular emergencies
  4. Endovascular management
  5. Anaesthetic management of vascular emergencies
  6. Strategies to reduce morbidity
  7. Postoperative management
  8. Acknowledgements
  9. Competing interests
  10. References

Pre-operative assessment/optimisation

One of the major challenges is the inadequate time to evaluate and optimise patients who present with a vascular emergency. Especially for rAAA, the aim is to minimise door to cross clamp time; however, where possible (i.e. the patient is conscious) a brief targeted assessment should address allergies, medications, cardiac history, routine blood tests, an arterial blood gas and ECG. It is clear that vascular patients are amongst those with the highest peri-operative risk. The American College of Cardiology/American Heart Association 2007 peri-operative cardiovascular evaluation and care for non-cardiac surgery guidelines [51] and 2009 update [52] rank major vascular surgery as high-risk even in the elective setting. Atherosclerosis affects vessels systemically and the anaesthetist should assume involvement of the coronary, cerebral and renal circulations.

Aortic dissections occur in a slightly different and younger population with connective tissue and congenital conditions playing a greater role. These conditions present anaesthetic implications beyond the vascular emergency (Table 1). Thoracic aortic trauma often occurs in young patients [10], often with other life-threatening injuries.

Table 1. Clinical features and anaesthetic implications of conditions that predispose to aortic dissection.
  Clinical featuresAnaesthetic implications
Marfan’s syndrome [53]Skeletal  Hypermobility  Sternal abnormalities  High arched palate Ocular  Lens dislocation  Retinal detachment Cardiovascular  Aortic dilation and aneurysm  Aortic dissection  Mitral valve prolapse Others  Dural ectasia  Lung disease (bronchogenic cysts, emphysema) Careful positioning (risk of joint dislocation) Bag-mask ventilation may be difficult Longer laryngoscope blades may be required Failed spinal anaesthesia and increased risk dural puncture with epidural (dural ectasia) Restrictive lung function (chest wall abnormalities) Spontaneous pneumothorax possible
Ehlers–Danlos (vascular, type IV) [54, 55]Hypermobile joints Extensible skin, fragile tissues Bleeding tendency Rupture of uterus, bowel and arteries Characteristic facial appearance Airway trauma/mucosal bleeding Difficult vascular access with increased complications Careful positioning (skin tears and joint dislocation) Cervical spine instability Bleeding risk including epidural haematoma
Turner syndrome [9, 56]Short stature, short neck & micrognathia Increased incidence of  Ischaemic heart disease  Aortic dissection  Bicuspid aortic valve  Aortic coarctation Difficult intubation Endobronchial intubation more likely Double-lumen tracheal tube positioning may be difficult
Loeys-Dietz syndrome [9]Triad: arterial aneurysms, hypertelorism & cleft palate or bifid uvula Also:  Craniosynostosis  Retrognathia  Abnormal cervical spine  Skeletal features similar to Marfan’s  Developmental delayDifficult airway management Development delay may preclude local anaesthesia alone

For aortic rupture, permissive hypotension should be a standard of care with the aim of keeping the systolic blood pressure 50–100 mmHg as long as consciousness is maintained [1, 36, 57]. Excessive fluid administration, in an attempt to normalise blood pressure, dilutes coagulation factors, disrupts thrombus and can cause expansion and rupture of a contained retroperitoneal haematoma [11]. For dissection, aortic wall stress should be minimised by keeping the heart rate <60 beats.min−1 and systolic blood pressure 100–120 mmHg [9, 58, 59]. Intravenous beta-adrenoceptor antagonists are ideal initial treatment and if systolic blood pressure remains more than 120 mmHg after adequate heart rate control, vasodilators are then added. Adequate pain control is an important adjunct.

Preparation of equipment and operating theatre

The location where anaesthesia will take place (operating theatre or interventional radiology) should be prepared with a similar check-list to that in Table 2. The establishment of monitoring is in part dictated by the time available before surgery. Attachment of an ECG, pulse oximeter and non-invasive blood pressure (NIBP) cuff causes no delays. Pre-induction invasive arterial monitoring is optimal; however, if not rapidly achieved, it can be obtained after the aorta is cross clamped, with NIBP measurements taken every minute in the interim. The right arm is usually preferable since an aortic occlusion balloon placed via the left brachial artery or the left subclavian artery may be involved in a type B dissection or require coverage by an endograft. For most thoracic aortic emergencies, two arterial lines are ideal – one in the right arm and one ‘post-subclavian’ either in the left upper limb or a femoral artery.

Table 2. Suggested preparation and anaesthetic equipment for a vascular emergency.
 Equipment & preparation
MonitoringStandard monitors (NIBP, pulse oximeter, five lead ECG) Arterial, central ± pulmonary artery catheter, lines + transducers Temperature probe Urinary catheter
Fluid/blood productsAlert blood bank, cross match minimum four units packed red blood cells Rapid infusor Fluid warmers (×2 ideal) Cell saver
Anaesthetic agents Emergency drugsInduction drugs (consider ketamine) Metaraminol or phenylephrine boluses Dilute adrenaline i.e. 4 microg.ml−1 for boluses Atropine Calcium chloride (1 g in 10 ml × 1–2) Sodium bicarbonate (50 ml 8.4% solution × 1–2) Insulin and dextrose (hyperkalaemia treatment) Nitroglycerin (to treat clamping related hypertension) Vasopressor and inotrope infusions (noradrenaline, adrenaline etc.)
Prophylactic antibiotics Other equipmentForced air warmer Double lumen tracheal tube (should be available for thoracic aortic surgery including TEVAR in case of rupture)
Specialised monitoring(consider)Transoesophageal echocardiography Depth of anaesthesia monitor (given the high risk of intra-operative awareness)

Use of central venous access is determined on a case-by-case basis. A pulmonary artery catheter may be considered and whilst RCT evidence suggested no added mortality resulting from pulmonary artery catheter guided treatment, equally no benefit was seen [60]. Intra-operative transoesophageal echocardiography (TOE) improves detection of regional wall motion abnormalities, and helps guide management of volume resuscitation and haemodynamic changes during clamping and unclamping. TOE can be used to confirm left atrial cannula position during left heart bypass and assists endograft positioning; the true vs false dissection lumens can be identified, and detection of the endovascular guidewire within the false lumen using TOE [61] can avert disaster.

Single lung ventilation is required for open thoracic aortic repairs. Pathology of the thoracic aorta may distort or compress the left main bronchus, making placement of a left-sided double-lumen tracheal tube difficult or hazardous [62]. A right-sided double-lumen tube or bronchial blocker can be used as an alternative. If postoperative ventilation in ICU is planned, conversion to a single-lumen tube is performed before transfer.

General vs local anaesthesia

Open emergency aortic operations are traditionally performed under general anaesthesia. However, for endovascular procedures, particularly those with percutaneous groin access, local anaesthesia ± sedation has become a viable option. Neuraxial techniques have been described for emergency procedures [63]; however, surgical urgency, limited patient co-operation and thrombolysis often preclude their use. If neuraxial techniques are used, timing in relation to anticoagulation and antiplatelet agents must be considered [64].

When a rAAA proceeds under general anaesthesia, it is usual to prep and drape the patient before induction to minimise time to clamp after loss of abdominal wall tone. Ketamine achieves rapid blood-brain equilibration and acts as a sympathomimetic, making it an ideal agent for a rapid sequence induction in a haemodynamically compromised patient [65]. Embolectomy and other lower limb revascularisation procedures can proceed under local infiltration, unless fasciotomy is required. For EVAR or TEVAR, local anaesthesia can be used for the initial part of the procedure, followed by induction of general anaesthesia after the aorta is secured and before exposure of the contra-lateral femoral artery and femoro-femoral crossover, if required. Several studies have proven the feasibility of performing EVAR for rAAA under LA [36, 50, 66, 67]. Table 3 outlines the benefits vs disadvantages of each option.

Table 3. Benefits and disadvantages of local anaesthesia (LA) vs general anaesthesia (GA) for emergency vascular operations.
 BenefitsDisadvantages
LASpontaneous ventilation preserving venous return Fewer respiratory complications Improved immediate postoperative analgesiaExtensive groin dissection, or femoro–femoral bypass precludes LA alone Patient co-operation may be limited Pain from retroperitoneal haematoma, tourniquet or lower limb ischaemia can be problematic Transoesophageal echocardiography cannot be used Acid-base derangements following reperfusion are challenging to manage in a spontaneously breathing patient
GAApnoea, induced hypotension and patient immobility during stent deployment more easily achieved Transoesophageal echocardiography can be used Rapid conversion to open repair if required Optimal surgical conditionsLoss of tamponade effect of abdominal muscle tone Potential for GA-induced cardiovascular collapse

Is local anaesthesia a better choice?

For elective vascular surgery, several studies have shown a reduction in cardiac morbidity [68, 69] and a dramatic reduction in vascular graft occlusion [68, 70, 71] linked to regional anaesthesia. Elective EVAR using local anaesthesia has demonstrated benefits including reduced ICU and hospital stay [72–75] and decreased pulmonary morbidity [75]. A meta-analysis of 39 articles and 2387 patients undergoing elective EVAR found that general anaesthesia was an independent risk factor for death, with an odds ratio of 5.1 (95% CI 1.9–13.3) [76].

In the emergency vascular literature, Karkos et al. reported in a small study that local anaesthesia for EVAR for rAAA was a significant predictor of survival [77]. However, in another study, patients presenting with acute lower limb ischaemia who had their procedure under local anaesthesia (41%) had worse outcomes as an anaesthetist was not present and these two factors are likely to be linked [7]. Once again, level one evidence is lacking. A given technique must be appropriately applied for the patient and circumstances. Meticulous attention to detail within the chosen technique is arguably more important than the technique itself.

Blood loss and coagulation management

If staffing allows, one anaesthetist should be assigned to manage fluids, blood products and blood samples to guide transfusion strategy. Most open operations on the aorta result in considerable blood loss secondary to aortic rupture, disruption of retroperitoneal vessels during dissection and coagulopathy. Coagulopathy develops due to hypothermia, dilution, acidosis and fibrinolysis induced by the aortic cross clamp. Lysine analogues (i.e. tranexamic acid) are sometimes used to minimise fibrinolysis based on the strong evidence seen in cardiac surgery. However, use in aortic surgery without cardiopulmonary bypass does not have the same body of evidence [9].

In a patient with ongoing bleeding, our current practice is to maintain their haemoglobin concentration >  9 g.dl−1, INR < 1.5, platelets >  100 × 109.l−1 and fibrinogen >  2 g.l−1. Laboratory-based coagulation tests (with inherent delays) or point-of-care tests such as thromboelastography (TEG) can be used. A study from Denmark compared a standardised transfusion strategy in patients having open repair of rAAA, with historical controls. A ‘transfusion package’ comprising packed red blood cells, fresh frozen plasma and platelet concentrates was combined with TEG analysis to guide transfusion therapy [78]. There was a reduction in 30-day mortality from 56% (control group) to 34% (intervention group) (p = 0.02) at the expense of increased transfusion. Cell salvage should be considered when anticipated blood loss is >  1000 ml [79]. A retrospective study of cell salvage during rAAA found that allogenic blood use was reduced by an average of three units per patient [80]. A recent Cochrane review concluded that cell salvage reduced peri-operative allogenic blood transfusion although other clinical outcomes were not altered [81], but this was not specific for vascular surgery.

Cross clamping

For open aortic repairs, the anaesthetist must be prepared to manage the haemodynamic effects of aortic cross clamping and unclamping as outlined in two excellent reviews [82, 83]. Venodilators (e.g. nitroglycerin) are useful for clamping-related hypertension to increase venous capacitance, reduce preload [83] and permit fluid loading in preparation for unclamping. Arteriolar dilators (e.g. nitroprusside) should be used with caution as the reduction in both distal and proximal aortic pressure can further affect perfusion distal to the clamp [82]. An increased incidence of spinal cord injury attributed to nitroprusside is probably due to a combination of decreased distal aortic pressure and increased cerebrospinal fluid (CSF) pressure secondary to cerebral vasodilation [82, 83].

Preparation for unclamping includes volume replacement, aggressive treatment of acidosis and close communication between surgeon and anaesthetist. Venodilators should be discontinued and the anaesthetist should be prepared to treat with calcium, bicarbonate, hyperventilation, vasopressors and fluid. By gradually releasing the cross clamp and/or reperfusing the lower limbs one at a time, the washout of cardio-depressant mediators is slowed, re-oxygenation is delayed and the production of oxygen free radicals is decreased [82]. If unclamping is poorly tolerated, reclamping can temporarily stabilise the patient. Reperfusion following an ischaemic insult (i.e. embolus) should be managed as for unclamping.

Hypothermia

Normothermia should be maintained with warming beginning before induction. Warming fluid and blood products, increasing ambient temperature and forced air-warming blankets can minimise heat loss. Active warming of the legs during cross clamp must be avoided as limb ischaemia will be exacerbated. A retrospective study of patients with rAAA compared survivors with non-survivors, with survivors showing higher mean temperature on arrival to the operating theatre and higher intra-operative and end-of-procedure temperatures [84].

Strategies to reduce morbidity

  1. Top of page
  2. Summary
  3. Overview of vascular emergencies
  4. Endovascular management
  5. Anaesthetic management of vascular emergencies
  6. Strategies to reduce morbidity
  7. Postoperative management
  8. Acknowledgements
  9. Competing interests
  10. References

Renal

The incidence of renal failure after rTAAA repair is reported to be between 4% and 40% [5] and 16–26% following rAAA repair [3, 85, 86]. Prolonged clamp time, hypotension, decreased cardiac output, anaemia, high contrast load in endovascular techniques and pre-existing renal impairment [86, 87] are important risk factors. Myoglobinuria from rhabdomyolysis, iatrogenic ureteric injuries and nephrotoxic drugs contribute to renal dysfunction.

There is no level-one evidence to support the use of N-acetyl-cysteine [88], dopamine [89, 90], loop diuretics or mannitol [91] to prevent renal impairment. The main protection goals are maintenance of the balance between renal oxygen supply and demand with normovolaemia, adequate cardiac output and haemoglobin concentration. Suprarenal clamping duration should be minimised and cold renal perfusion to reduce the metabolic demands of the kidney may be a useful adjunct [5, 92].

Spinal cord protection

Spinal cord injury occurs in 2–10% [9] of elective operations on the thoracic aorta with a higher incidence in the emergency setting [93]. Prevention focuses on maintenance of spinal cord perfusion pressure (maintenance of mean arterial pressure, CSF drainage, left heart bypass [94, 95]) and increasing ischaemic tolerance (steroids, hypothermia.) Two RCTs have shown that CSF drainage reduces paraplegia in patients having elective TAAA repair [96, 97] and another failed to demonstrate a difference [98]. A meta-analysis comprising these three RCT and 11 additional cohort studies supported CSF drainage as an adjunct to prevent paraplegia [99]. However, a Cochrane review [100] of the RCTs alone concluded that there are limited supportive data.

Complications of CSF drainage include headache, persistent CSF leak, subdural or epidural haematoma and meningitis. Wynn et al. reported a 1% incidence of neurological deficit and 0.6% mortality related to CSF drainage [101]. Dardik et al. reported the incidence of symptomatic subdural haematomas to be 3.5% with a mortality of 50% [102]. These risks may be reduced by limiting the volume of CSF removed and avoiding postoperative drainage in asymptomatic patients [101, 102]. If a CSF drain has not been inserted pre-operatively, as is often the case in the emergency setting, it can still be placed postoperatively if symptoms develop, which may reverse paraplegia [103–106].

Postoperative management

  1. Top of page
  2. Summary
  3. Overview of vascular emergencies
  4. Endovascular management
  5. Anaesthetic management of vascular emergencies
  6. Strategies to reduce morbidity
  7. Postoperative management
  8. Acknowledgements
  9. Competing interests
  10. References

Most patients require ICU care postoperatively with monitoring for complications, further rewarming and ongoing treatment of coagulopathy. Persistent hypotension may be caused by adrenal insufficiency resulting from interruption of adrenal blood supply (suprarenal clamping), adrenal haemorrhage [107], or a systemic inflammatory response causing down-regulation of the hypothalamic-pituitary-adrenal axis. An unexpectedly high incidence was seen in one small study [107].

Abdominal compartment syndrome (intra-abdominal pressure >  20 mmHg with new organ dysfunction) [108] has a 4–12% incidence following open repair of rAAA [109]. Some endovascular series have shown higher rates [110] due to an inability to evacuate retroperitoneal haematoma. Risk factors include hypotension, hypothermia, acidosis, aggressive fluid/blood product resuscitation, anaemia [1, 111, 112] and the need for an aortic occlusion balloon [110]. Some authors recommend postoperative monitoring of intra-abdominal pressure via bladder pressure [1, 113, 114] or even surveillance colonoscopy in patients at increased risk [111, 115]. Others suggest delayed abdominal closure in patients with multiple risk factors [112].

Delirium is a well-recognised complication after vascular surgery that affects over 30% of patients [116, 117] and is associated with prolonged stay and higher morbidity and mortality [118, 119]. Independent predictors of delirium include older age, history of cerebrovascular accident and pre-operative beta-adrenoceptor antagonist administration [120]. Endovascular repair of AAA was associated with significantly lower postoperative delirium when compared with an open approach, irrespective of age [121].

For patients who present with a vascular emergency, perioperative morbidity and mortality remains alarmingly high. The increasingly-used endovascular approach shows promise to reduce overall mortality, although, whatever the impact on mortality, endovascular surgery has created additional considerations for the anaesthetist including the potential to proceed under local anaesthesia alone.

Acknowledgements

  1. Top of page
  2. Summary
  3. Overview of vascular emergencies
  4. Endovascular management
  5. Anaesthetic management of vascular emergencies
  6. Strategies to reduce morbidity
  7. Postoperative management
  8. Acknowledgements
  9. Competing interests
  10. References

The authors acknowledge the assistance of Marina Englesakis, UHN Health Sciences Library, for her assistance with the literature review.

References

  1. Top of page
  2. Summary
  3. Overview of vascular emergencies
  4. Endovascular management
  5. Anaesthetic management of vascular emergencies
  6. Strategies to reduce morbidity
  7. Postoperative management
  8. Acknowledgements
  9. Competing interests
  10. References
  • 1
    Moll FL, Powell JT, Fraedrich G, et al.Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. European Journal of Vascular and Endovascular Surgery2011; 41 (Suppl. 1): S1S58.
  • 2
    Karkos CD, Harkin DW, Giannakou A, Gerassimidis TS. Mortality after endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis. Archives of Surgery2009; 144: 7708.
  • 3
    Leo E, Biancari F, Nesi F, et al.Risk-scoring methods in predicting the immediate outcome after emergency open repair of ruptured abdominal aortic aneurysm. American Journal of Surgery2006; 192: 1923.
  • 4
    Mohan IV, Hitos K, White GH, et al.Improved outcomes with endovascular stent grafts for thoracic aorta transections. European Journal of Vascular and Endovascular Surgery2008; 36: 1527.
  • 5
    Escobar GA, Upchurch GR. Management of thoracoabdominal aortic aneurysms. Current Problems in Surgery2011; 48: 70133.
  • 6
    Suzuki T, Mehta RH, Ince H, et al.Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD). Circulation2003; 108 (Suppl. 1): 3127.
  • 7
    Morris-Stiff G, D’Souza J, Raman S, Paulvannan S, Lewis MH. Update experience of surgery for acute limb ischaemia in a district general hospital – are we getting any better?Annals of the Royal College of Surgeons of England2009; 91: 63740.
  • 8
    Howard-Alpe G, Stoneham M. Anaesthesia for vascular emergencies. Anaesthesia and Intensive Care Medicine2010; 11: 18790.
  • 9
    Hiratzka LF, Bakris GL, Beckman JA, et al.2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association. Circulation2010; 121: e266369.
  • 10
    Tang GL, Tehrani HY, Usman A, et al.Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysisJournal of Vascular Surgery2008; 47: 6715.
  • 11
    Tambyraja AL, Chalmers RTA. Aortic aneurysms. Surgery2009; 27: 3425.
  • 12
    Leonard A, Thompson J. Anaesthesia for ruptured abdominal aortic aneurysm. Continuing Education in Anaesthesia Critical Care and Pain2008; 8: 115.
  • 13
    Lewis A, Kirk G, McKinley A, Blair PH, Harkin DW. The role of transthoracic echocardiography in embolic acute limb ischaemia. Irish Journal of Medical Science2009; 178: 4579.
  • 14
    Costantini V, Lenti M. Treatment of acute occlusion of peripheral arteries. Thrombosis Research2002; 106: V28594.
  • 15
    Rutherford RB, Baker JD, Ernst C, et al.Recommended standards for reports dealing with lower extremity ischemia: revised version. Journal of Vascular Surgery1997; 26: 51738.
  • 16
    Allaqaband S, Solis J, Kazemi S, Bajwa T. Endovascular treatment of peripheral vascular disease. Current Problems in Cardiology2006; 31: 71160.
  • 17
    Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Annals of Vascular Surgery1991; 5: 4919.
  • 18
    Yusuf SW, Whitaker SC, Chuter TAM, Wenham PW, Hopkinson BR. Emergency endovascular repair of leaking aortic aneurysm. Lancet1994; 344: 1645.
  • 19
    Marin ML, Veith FJ, Cynamon J, et al.Initial experience with transluminally placed endovascular grafts of the treatment of complex vascular lesions. Annals of Surgery1995; 222: 44965.
  • 20
    Najjar SF, Mueller KH, Ujiki MB, Morasch MD, Matsumura JS, Eskandari MK. Percutaneous endovascular repair of ruptured abdominal aortic aneurysms. Archives of Surgery2007; 142: 104952.
  • 21
    Castelli P, Caronno R, Piffaretti G, et al.Ruptured abdominal aortic aneurysm: endovascular treatment. Abdominal Imaging2005; 30: 2639.
  • 22
    Matsumura JS, Lee WA, Mitchell RS, et al.The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. Journal of Vascular Surgery2009; 50: 11558.
  • 23
    Arthurs Z, Starnes B, See C, Andersen C. Clamp before you cut: proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion. Case reports. Vascular and Endovascular Surgery2006; 40: 14955.
  • 24
    Philipsen TE, Hendriks JM, Lauwers P, et al.The use of rapid endovascular balloon occlusion in unstable patients with ruptured abdominal aortic aneurysm. Innovations2009; 4: 749.
  • 25
    Slater BJ, Harris EJ, Lee JT. Anatomic suitability of ruptured abdominal aortic aneurysms for endovascular repair. Annals of Vascular Surgery2008; 22: 71622.
  • 26
    Hoornweg LL, Wisselink W, Vahl A, Balm R. The Amsterdam acute aneurysm trial: suitability and application rate for endovascular repair of ruptured abdominal aortic aneurysms. European Journal of Vascular and Endovascular Surgery2007; 33: 67983.
  • 27
    Lloyd GM, Bown MJ, Norwood MGA, et al.Feasibility of preoperative computer tomography in patients with ruptured abdominal aortic aneurysm: a time-to-death study in patients without operation. Journal of Vascular Surgery2004; 39: 78891.
  • 28
    Coady MA, Ikonomidis JS, Cheung AT, et al.Surgical management of descending thoracic aortic disease: open and endovascular approaches: a scientific statement from the American Heart Association. Circulation2010; 121: 2780804.
  • 29
    Greenhalgh RM, Brown LC, Kwong GPS, et al.Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet2004; 364: 8438.
  • 30
    Prinssen M, Verhoeven ELG, Buth J, et al.A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. New England Journal of Medicine2004; 351: 160718.
  • 31
    Lederle FA, Freischlag JA, Kyriakides TC, et al.Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. Journal of the American Medical Association2009; 302: 153542.
  • 32
    Greenhalgh RM, Brown LC, Epstein D, et al.Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet2005; 365: 217986.
  • 33
    Blankensteijn JD, de Jong SE, Prinssen M, et al.Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. New England Journal of Medicine2005; 352: 2398405.
  • 34
    Mehta M, Taggert J, Darling RC, et al.Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: outcomes of a prospective analysis. Journal of Vascular Surgery2006; 44: 18.
  • 35
    Lyons OT, Black S, Clough RE, et al.Emergency endovascular aneurysm repair for ruptured abdominal aortic aneurysm: the way forward?Vascular2010; 18: 1305.
  • 36
    Mayer D, Pfammatter T, Rancic Z, et al.10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned. Annals of Surgery2009; 249: 5105.
  • 37
    Verhoeven EL, Kapma MR, Bos WT, et al.Mortality of ruptured abdominal aortic aneurysm with selective use of endovascular repair. Journal of Cardiovascular Surgery2009; 50: 58793.
  • 38
    Harkin DW, Dillon M, Blair PH, Ellis PK, Kee F. Endovascular ruptured abdominal aortic aneurysm repair (EVRAR): a systematic review. European Journal of Vascular and Endovascular Surgery2007; 34: 67381.
  • 39
    Mastracci TM, Garrido-Olivares L, Cinà CS, Clase CM. Endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis. Journal of Vascular Surgery2008; 47: 21421.
  • 40
    Azizzadeh A, Villa MA, Miller CC, Estrera AL, Coogan SM, Safi HJ. Endovascular repair of ruptured abdominal aortic aneurysms: systematic literature review. Vascular2008; 16: 21924.
  • 41
    Rayt HS, Sutton AJ, London NJ, Sayers RD, Bown MJ. A systematic review and meta-analysis of endovascular repair (EVAR) for ruptured abdominal aortic aneurysm. European Journal of Vascular and Endovascular Surgery2008; 36: 53644.
  • 42
    Hinchliffe RJ, Bruijstens L, MacSweeney ST, Braithwaite BD. A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm – results of a pilot study and lessons learned for future studies. European Journal of Vascular and Endovascular Surgery2006; 32: 50613.
  • 43
    Desgranges P, Kobeiter H, Castier Y, Senechal M, Majewski M, Krimi A. The Endovasculaire vs Chirurgie dans les Anévrysmes Rompus PROTOCOL trial update. Journal of Vascular Surgery2010; 51: 26770.
  • 44
    Doss M, Balzer J, Martens S, et al.Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience. Annals of Thoracic Surgery2003; 76: 14659.
  • 45
    Conrad MF, Ergul EA, Patel VI, Paruchuri V, Kwolek CJ, Cambria RP. Management of diseases of the descending thoracic aorta in the endovascular era: a Medicare population study. Annals of Surgery2010; 252: 60310.
  • 46
    Fattori R, Tsai TT, Myrmel T, et al.Complicated acute type B dissection: is surgery still the best option? A report from the International Registry of Acute Aortic Dissection. Journal of the American College of Cardiology: Cardiovascular Interventions2008; 1: 395402.
  • 47
    Parker JD, Golledge J. Outcome of endovascular treatment of acute type B aortic dissection. Annals of Thoracic Surgery2008; 86: 170712.
  • 48
    Xu SD, Huang FJ, Yang JF, et al.Endovascular repair of acute type B aortic dissection: early and mid-term results. Journal of Vascular Surgery2006; 43: 10905.
  • 49
    Cayne NS, Veith FJ. Ruptured abdominal aortic aneurysms: role of endovascular therapy. Mount Sinai Journal of Medicine2010; 77: 2505.
  • 50
    Peppelenbosch N, Geelkerken RH, Soong C, et al.Endograft treatment of ruptured abdominal aortic aneurysms using the Talent aortouniiliac system: an international multicenter study. Journal of Vascular Surgery2006; 43: 111123.
  • 51
    Fleisher LA, Beckman JA, Brown KA, et al.ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation2007; 116: 197196.
  • 52
    Fleischmann KE, Beckman JA, Buller CE, et al.2009 ACCF/AHA focused update on perioperative beta blockade. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation2009; 120: 212351.
  • 53
    Bösenberg MT, Bösenberg AT. Anaesthesia for Marfan’s syndrome. South African Journal of Anaesthesia and Analgesia2007; 13: 159.
  • 54
    Lane D. Anaesthetic implications of vascular type Ehlers-Danlos syndrome. Anaesthesia and Intensive Care2006; 34: 5015.
  • 55
    Johnston BA, Occhipinti KE, Baluch A, Kaye AD. Ehlers-Danlos syndrome: complications and solutions concerning anesthetic management. Middle Eastern Journal of Anesthesiology2006; 18: 117184.
  • 56
    Mashour GA, Sunder N, Acquadro MA. Anesthetic management of Turner syndrome: a systematic approach. Journal of Clinical Anesthesia2005; 17: 12830.
  • 57
    Chaikof EL, Brewster DC, Dalman RL, et al.The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. Journal of Vascular Surgery2009; 50: S249.
  • 58
    Erbel R, Alfonso F, Boileau C, et al.Diagnosis and management of aortic dissection. Recommendations of the Task Force on Aortic Dissection, European Society of Cardiology. European Heart Journal2001; 22: 164281.
  • 59
    Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: part II: therapeutic management and follow-upCirculation2003; 108: 7728.
  • 60
    Sandham JD, Hull RD, Brant RF, et al.A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. New England Journal of Medicine2003; 348: 514.
  • 61
    Rapezzi C, Rocchi G, Fattori R, et al.Usefulness of transesophageal echocardiographic monitoring to improve the outcome of stent-graft treatment of thoracic aortic aneurysms. American Journal of Cardiology2001; 87: 3159.
  • 62
    Cohen JA, Denisco RA, Richards TS, Staples ED, Roberts AJ. Hazardous placement of a Robertshaw-type endobronchial tube. Anesthesia and Analgesia1986; 65: 1001.
  • 63
    Leykin Y, Rubulotta FM, Mancinelli P, Tosolini G, Gullo A. Epidural anaesthesia for endovascular stent graft repair of a ruptured thoracic aneurysm. Anaesthesia and Intensive Care2003; 31: 45560.
  • 64
    Horlocker TT, Wedel DJ, Rowlingson JC, et al.Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Regional Anesthesia and Pain Medicine2010; 35: 64101.
  • 65
    Morris C, Perris A, Klein J, Mahoney P. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?Anaesthesia2009; 64: 5329.
  • 66
    Gerassimidis TS, Karkos CD, Karamanos DG, et al.Endovascular management of ruptured abdominal aortic aneurysms: an 8-year single-centre experience. Cardiovascular and Interventional Radiology2009; 32: 2419.
  • 67
    Coppi G, Silingardi R, Gennai S, Saitta G, Ciardullo AV. A single-center experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms. Journal of Vascular Surgery2006; 44: 11407.
  • 68
    Tuman KJ, McCarthy RJ, March RJ, DeLaria GA, Patel RV, Ivankovich AD. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesthesia and Analgesia1991; 73: 696704.
  • 69
    Yazigi A, Madi-Gebara S, Haddad F, Hayeck G, Tabet G. Intraoperative myocardial ischemia in peripheral vascular surgery: general anesthesia vs combined sciatic and femoral nerve blocks. Journal of Clinical Anesthesia2005; 17: 499503.
  • 70
    Christopherson R, Beattie C, Frank SM, et al.Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Anesthesiology1993; 79: 42234.
  • 71
    Kashyap VS, Ahn SS, Quinones-Baldrich WJ, et al.Infrapopliteal-lower extremity revascularization with prosthetic conduit: a 20-year experience. Vascular and Endovascular Surgery2002; 36: 25562.
  • 72
    Bettex DA, Lachat M, Pfammatter T, Schmidlin D, Turina MI, Schmid ER. To compare general, epidural and local anaesthesia for endovascular aneurysm repair (EVAR). European Journal of Vascular and Endovascular Surgery2001; 21: 17984.
  • 73
    Ruppert V, Leurs LJ, Steckmeier B, Buth J, Umscheid T. Influence of anesthesia type on outcome after endovascular aortic aneurysm repair: an analysis based on EUROSTAR data. Journal of Vascular Surgery2006; 44: 1621.
  • 74
    Verhoeven EL, Cinà CS, Tielliu IF, et al.Local anesthesia for endovascular abdominal aortic aneurysm repair. Journal of Vascular Surgery2005; 42: 4029.
  • 75
    Edwards MS, Andrews JS, Edwards AF, et al.Results of endovascular aortic aneurysm repair with general, regional, and local/monitored anesthesia care in the American College of Surgeons National Surgical Quality Improvement Program database. Journal of Vascular Surgery2011; 54: 127382.
  • 76
    Walschot LH, Laheij RJ, Verbeek AL. Outcome after endovascular abdominal aortic aneurysm repair: a meta-analysis. Journal of Endovascular Therapy2002; 9: 829.
  • 77
    Karkos CD, Karamanos D, Papazoglou KO, et al.Usefulness of the Hardman index in predicting outcome after endovascular repair of ruptured abdominal aortic aneurysms. Journal of Vascular Surgery2008; 48: 78894.
  • 78
    Johansson PI. Goal-directed hemostatic resuscitation for massively bleeding patients: the Copenhagen concept. Transfusion and Apheresis Science2010; 43: 4015.
  • 79
    Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. British Journal of Anaesthesia2010; 105: 40116.
  • 80
    Serracino-Inglott F, Awad S, Barclay A, Nasim A. The use of a cell saver during repair of ruptured abdominal aortic aneurysms increases early survival. Annals of the Royal College of Surgeons England2005; 87: 475.
  • 81
    Carless PA, Henry DA, Moxey AJ, O’Connell D, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion (Review). Cochrane Database of Systematic Reviews2010; 4: CD001888 2: 1–190.
  • 82
    Gelman S. The pathophysiology of aortic cross-clamping and unclamping. Anesthesiology1995; 82: 102657.
  • 83
    Posner M, Gelman S. Pathophysiology of aortic cross-clamping and unclamping. Bailliere’s Clinical Anaesthesiology2000; 14: 14360.
  • 84
    Quiroga E, Tran NT, Hatsukami T, Starnes BW. Hypothermia is associated with increased mortality in patients undergoing repair of ruptured abdominal aortic aneurysm. Journal of Endovascular Therapy2010; 17: 4348.
  • 85
    Lo A, Adams D. Ruptured abdominal aortic aneurysms: risk factors for mortality after emergency repair. New Zealand Medical Journal2004; 117: 110010.
  • 86
    Cho JS, Kim JY, Rhee RY, et al.Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality. Journal of Vascular Surgery2008; 48: 108.
  • 87
    Alric P, Hinchliffe RJ, Picot MC, et al.Long-term renal function following endovascular aneurysm repair with infrarenal and suprarenal aortic stent-grafts. Journal of Endovascular Therapy2003; 10: 397405.
  • 88
    Macedo E, Abdulkader R, Castro I, Sobrinho AC, Yu L, Vieira JM. Lack of protection of N-acetylcysteine (NAC) in acute renal failure related to elective aortic aneurysm repair – a randomized controlled trial. Nephrology Dialysis Transplantation2006; 21: 18639.
  • 89
    Bellomo R, Chapman M, Finfer S, et al.Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Lancet2000; 356: 213943.
  • 90
    Friedrich JO, Adhikari N, Herridge MS, Beyene J. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Annals of Internal Medicine2005; 142: 51024.
  • 91
    Hersey P, Poullis M. Does the administration of mannitol prevent renal failure in open abdominal aortic aneurysm surgery?Interactive Cardiovascular and Thoracic Surgery2008; 7: 9069.
  • 92
    Schmitto JD, Fatehpur S, Tezval H, et al.Hypothermic renal protection using cold histidine-tryptophan-ketoglutarate solution perfusion in suprarenal aortic surgery. Annals of Vascular Surgery2008; 22: 5204.
  • 93
    Barbato JE, Kim JY, Zenati M, et al.Contemporary results of open repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms. Journal of Vascular Surgery2007; 45: 66776.
  • 94
    Schepens MA, Defauw JJ, Hamerlijnck RP, Vermeulen FE. Use of left heart bypass in the surgical repair of thoracoabdominal aortic aneurysms. Annals of Vascular Surgery1995; 9: 32738.
  • 95
    Coselli JS. The use of left heart bypass in the repair of thoracoabdominal aortic aneurysms: current techniques and results. Seminars in Thoracic and Cardiovascular Surgery2003; 15: 32632.
  • 96
    Coselli JS, LeMaire SA, Köksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. Journal of Vascular Surgery2002; 35: 6319.
  • 97
    Svensson LG, Hess KR, D’Agostino RS, et al.Reduction of neurologic injury after high-risk thoracoabdominal aortic operation. Annals of Thoracic Surgery1998; 66: 1328.
  • 98
    Crawford ES, Svensson LG, Hess KR, et al.A prospective randomized study of cerebrospinal fluid drainge to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. Journal of Vascular Surgery1990; 13: 3646.
  • 99
    Cina CS, Abouzahr L, Arena GO, Lagana A, Devereaux PJ, Farrokhyar F. Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis. Journal of Vascular Surgery2004; 40: 3644.
  • 100
    Khan SN, Stansby GP. Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery (Review). The Cochrane Collaboration2008; 3: 118.
  • 101
    Wynn MM, Mell MW, Tefera G, Hoch JR, Acher CW. Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008. Journal of Vascular Surgery2009; 49: 2935.
  • 102
    Dardik A, Perler BA, Roseborough GS, Williams GM. Subdural hematoma after thoracoabdominal aortic aneurysm repair: an underreported complication of spinal fluid drainage?Journal of Vascular Surgery2002; 36: 4750.
  • 103
    Lee WA, Daniels MJ, Beaver TM, Klodell CT, Raghinaru DE, Hess PJ. Late outcomes of a single-center experience of 400 consecutive thoracic endovascular aortic repairs. Circulation2011; 123: 293845.
  • 104
    Hnath JC, Mehta M, Taggert JB, et al.Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: outcomes of a prospective cerebrospinal fluid drainage protocol. Journal of Vascular Surgery2008; 48: 83640.
  • 105
    Ortiz-Gómez JR, Golzález-Solis F, Fernández-Alonso L, Bilbao J. Reversal of acute paraplegia with cerebrospinal fluid drainage after endovascular thoracic aortic aneurysm repair. Anesthesiology2001; 95: 12889.
  • 106
    Cheung AT, Weiss SJ, McGarvey ML, et al.Interventions for reversing delayed-onset postoperative paraplegia after thoracic aortic reconstruction. Annals of Thoracic Surgery2002; 74: 4139.
  • 107
    Parikshak M, Shepard AD, Reddy DJ, Nypaver TJ. Adrenal insufficiency in patients with ruptured abdominal aortic aneurysms. Journal of Vascular Surgery2004; 39: 94450.
  • 108
    Cheatham ML, Malbrain ML, Kirkpatrick A, et al.Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome II. Recommendations. Intensive Care Medicine2007; 33: 95162.
  • 109
    Trani JL, Farber MA. Stent-graft use in urgent and emergent AAA management. Journal of Cardiovascular Surgery2009; 50: 57585.
  • 110
    Mehta M, Darling RC, Roddy SP, et al.Factors associated with abdominal compartment syndrome complicating endovascular repair of ruptured abdominal aortic aneurysms. Journal of Vascular Surgery2005; 42: 104751.
  • 111
    Megalopoulos A, Vasiliadis K, Tsalis K, et al.Reliability of selective surveillance colonoscopy in the early diagnosis of colonic ischemia after successful ruptured abdominal aortic aneurysm repair. Vascular and Endovascular Surgery2008; 41: 50915.
  • 112
    Kimball EJ, Adams DM, Kinikini DV, Mone MC, Alder SC. Delayed abdominal closure in the management of ruptured abdominal aortic aneurysm. Vascular2009; 17: 30915.
  • 113
    Mehta M. Endovascular aneurysm repair for ruptured abdominal aortic aneurysm: the Albany Vascular Group approach. Journal of Vascular Surgery2010; 52: 170612.
  • 114
    Björck M, Wanhainen A, Djavani K, Acosta S. The clinical importance of monitoring intra-abdominal pressure after ruptured abdominal aortic aneurysm repair. Scandinavian Journal of Surgery2008; 97: 18390.
  • 115
    Champagne BJ, Darling RC, Daneshmand M, et al.Outcome of aggressive surveillance colonoscopy in ruptured abdominal aortic aneurysm. Journal of Vascular Surgery2004; 39: 7926.
  • 116
    Benoit AG, Campbell BI, Tanner JR, et al.Risk factors and prevalence of perioperative cognitive dysfunction in abdominal aneurysm patients. Journal of Vascular Surgery2005; 42: 88490.
  • 117
    Balasundaram B, Holmes J. Delirium in vascular surgery. European Journal of Vascular and Endovascular Surgery2007; 34: 1314.
  • 118
    Rosen SF, Clagett GP, Valentine RJ, Jackson MR, Modrall JG, McIntyre KE. Transient advanced mental impairment: an underappreciated morbidity after aortic surgery. Journal of Vascular Surgery2002; 35: 37681.
  • 119
    Inouye SK. Delirium in older persons. New England Journal of Medicine2006; 354: 115765.
  • 120
    Katznelson R, Djaiani G, Mitsakakis N, et al.Delirium following vascular surgery: increased incidence with preoperative beta-blocker administration. Canadian Journal of Anesthesia2009; 56: 793801.
  • 121
    Salata K, Katznelson R, Beattie WS, Carroll J, Lindsay TF, Djaiani G. Endovascular versus open approach to aortic aneurysm repair surgery: rates of postoperative delirium. Canadian Journal of Anesthesia2012; 59: 55661.