EVAR fever


In their editorial discussing the evolving world of vascular surgery, Wong and Irwin rightly highlight the challenges for training in vascular anaesthesia [1]. With increasing endovascular and hybrid procedures and a reduction in exposure to open aneurysm repair, how may future vascular anaesthetists gain the experience to manage these high-risk patients correctly?

The authors cite the importance of teamwork and experience in correctly using fluid therapy and vasoactive drugs to optimise the management of these patients. We would add other skills to that list. We believe that a vascular anaesthetist should also be an expert in the management of peri-operative acute coronary syndrome, arrhythmias and coagulopathy (guided by near-patient coagulation testing).

There is already, of course, a group of specialists with the optimal skill mix to provide this care, namely cardiac anaesthetists, who already anaesthetise for elective and emergency procedures of the ascending aorta and aortic arch and for hybrid procedures performed jointly by cardiac and vascular surgeons. Training in cardiac anaesthesia leads to expertise in the management of cardiovascular instability, ischaemia and major haemorrhage. Cardiac anaesthetists regularly deliver care in hybrid theatres for the rapidly evolving field of interventional cardiology, including percutaneous valve replacement. Many also combine their practice with work in specialist intensive care units (ICUs), making them ideally placed to manage the entire peri-operative course of complex vascular patients.

High-volume aneurysm centres are associated with significantly lower mortality for both open and endovascular repair [2, 3]. In the UK, the trend is towards further centralisation of super-specialist services, such that any patient with acute aortic pathology, irrespective of the origin/location of the dissection/rupture, can be transferred to a hospital with specialist surgical teams and ICUs capable of treating the whole aorta [4]. It is in such centres, where both cardiac and vascular services are available, that the volume and quality of training in vascular anaesthesia can be best achieved.

The expanding role of diagnostic echocardiography is discussed in the same issue of Anaesthesia by Greenhalgh and Patrick [4]. Transoesophageal echocardiography (TOE) is already used in many centres as an important tool for imaging the aorta during vascular surgery and as a valuable supplement to angiography [5]. In skilled hands it is an excellent monitor of ventricular and valvular function, can demonstrate intravascular devices well and is valuable in the haemodynamically unstable patient [4]. As technology evolves and probes become smaller and more user-friendly, it seems inevitable that echocardiography will have an ever increasing role in complex vascular procedures. Indeed, it is our contention that its widespread adoption in vascular surgery is a lost opportunity for vascular anaesthetists to embrace intra-operative TOE in the way that their cardiac colleagues have done over the previous two decades. Intensivists in the UK have successfully started to roll out the integration of echocardiography to improve patient care. For appointment to a substantive consultant cardiac anaesthetist post, accreditation in echocardiography is changing from a desirable criterion to an essential one.

We believe that the vascular anaesthetist could become a threatened species, particularly in the area of aortic surgery, and it is cardiac anaesthetists who are ideally placed to provide care for these patients. Whether cardiac anaesthesia could cope with such an increase in both elective and emergency workload is another question. Pressures such as the centralisation of aortic surgery into tertiary cardiovascular units and the expansion of peri-operative TOE will require increasing anaesthetic subspecialisation. Future anaesthetists may train, not as cardiothoracic or vascular anaesthetists, but as cardiovascular anaesthetists.