Vascular Anaesthesia

Richard Telford
Exeter

Summary

 Assessment of vascular patients

 Carotid endarterectomy (CEA)
 Abdominal aortic aneurysm (AAA) –open / emergency /EVAR
 Peripheral vascular disease
 Thoracic sympathectomy (26% pass rate mean score 7.7/20)

1
Vascular surgery is changing

 2019

 Older
 Multi-comorbid
 Renal failure
 2000  Amputations

 AAA
 CEA
 PVD

Assessment of fitness 1

1. Identify risk factors

(MI / CVA / CCF / Renal / DM / Resp / Frailty)

2. Evaluate functional capacity

(> 4METS)

3. Specify surgery risk

2
Risk stratification

High risk (>5% mortality) Intermediate Risk (<5%)

 Emergency intra abdominal  Head and neck

 Long operations/ high blood  Thoracic
loss  Intra abdominal
 AAA (emergency)  Major ortho
 Peripheral vascular  Major Urology
 Amputation  CEA

Assessment of fitness 2

4. Further non invasive evaluation (Shuttle walk/CPEX)

5. Further invasive evaluation (i.e. refer to cardiology)

6. Optimise Medical Rx
Aspirin / statin / BP control /ACEI / b blocker

7. Perform appropriate post op surveillance

8. Long term modification of risk factors

ACC/AHA Guideline for perioperative evaluation of patients

undergoing non-cardiac surgery Circulation 2014;130 :278-313

3
Create risk assessment
 Revised Lee cardiac risk assessment Circulation 1999

1. Risk of surgery
[Link]
3. CCF
4. CVA
[Link] RX
6. Raised Creatinine

0 points = 0.5% risk MI, death, cardiac arrest

3 points = > 11% risk

NYHA functional status / Duke activity Scale

Biomarkers - B natiuretic peptide
Ejection fraction

Carotid endarterectomy

Prophylactic operation to prevent embolic stroke

4
Carotid artery disease: atheromatous plaque at the bifurcation of the carotid artery

Erickson K M , Cole D J Br. J. Anaesth. 2010;105:i34-i49

Haemorrhagic plaque removed from an internal carotid artery at carotid

endarterectomy

10

5
Indications for surgery

1. Symptomatic TIA + >70% stenosis

(ECST 1998 Lancet)

2. Asymptomatic but > 60% stenosis

(ACST 2004 Lancet) only benefit in fitter
younger pts.

11

Indications and outcomes for CEA (NVR 2018)

67% Male

75% aged > 75

31% heart disease

24% diabetic

12

6
Carotid Endarterectomy - GA or LA?

2018 - 60% GA

13

Lancet 2008; 372: 2132–42

GALA trial

◼ GA vs. LA – patients enrolled over 8 years

◼ 3,526 patients
◼ 1,752 GA patients
◼ 1,771 LA patients

◼ Primary outcome 30 Days

Stroke/MI/Death
◼ 99.9% follow-up

14

7
GALA trial -results
• stroke GA 4.0% vs. LA 3.7%

• mortality at 30 days GA 1.5% vs. LA 1.1%

• MI LA 0.5% vs GA 0.2%

15

Conclusions - GALA
◼ Either technique is acceptable
◼ LA may be better in contralateral occlusion
◼ BP manipulation in GA patients is common
practice
◼ Outcomes improving
◼ ESCT 1998 Stroke/Death 7.5%
◼ NASCET 2004 Stroke/Death 6.5%
◼ GALA 2008 Stroke/Death/MI 4.7%
◼ NVR 2018 Stroke/Death 2.0%

16

8
CRQ: List the benefits of CEA under LA

1. Cerebral state assessment intra

and post operatively

2. More selective use of shunts

3. Greater stability of blood

pressure

4. Shorter hospital stay

17

CEA under LA - disadvantages

1. Operation technically more difficult and hurried leading

to poor results

2. Increased stress - to the patient

- to the surgeon

3. Opportunities for training

4. ?? Loss of neuro-protective effects of GA

18

9
CRQ. List the origin of the superficial cervical plexus, its
cutaneous location, and branches

• Origin: C2,3,4 cutaneous innervation only

• Location: deep to the superficial fascia at mid
point of posterior border of sternocleidomastoid
(Erb’s point)
• Branches:
– Greater and lesser occipital nerves - supply the occiput
– Greater auricular nerve – supplies back of ear and tip of
ear lobe
– Transverse cervical nerves
– Supraclavicular nerves - supply the skin above the
clavicle and over the tip of the shoulder (epaulet area)

19

1. Transverse C
2. Occipital
3. Supraclavicular
4. EJV
5. G. Auricular

20

10
CRQ. List the methods to achieve a LA block for CEA? (4 marks)

1. Local Infiltration by surgeon

2. Cervical epidural - Hanging drop technique C6/7 or C7/T1 Not popular!

Complications Altered pulmonary function 100%

3. Superficial cervical plexus block – subcutaneous along the posterior border

of SCM.10 -15 ml LA. Complications – Inadvertent injection into EJV

4. +/- Intermediate cervical plexus block – needle at the mid point of posterior
border of SCM. Single pop. 10 – 15 ml LA deep to investing fascia of the neck.
Complications - vascular structures

5. +/- Deep cervical plexus block

21

LA Carotid

Superficial CP Block
or
Superfical CP+ Deep Block CP

22

11
Regional anaesthesia for CEA
Stoneham et al
BJA 2015: 114 ; 372 - 383

 6 trials compare deep v superficial

 Superficial cervical plexus block ~ 7 lines
 Deep cervical plexus block ~ 38 lines

23

CRQ. List 5 complications associated with the deep

cervical plexus block.

1. Phrenic nerve block –don`t use in severe resp

disease
2. Intravascular injection. Vertebral artery 2-3 mm
from tip of transverse process.
3. Intathecal injection
4. Horner`s syndrome (stellate ganglion block C7-T1 –
ptosis, miosis, anhydrosis, enopthalmos)
5. Recurrent laryngeal nerve palsy. Bovine cough and
risk of aspiration

24

12
CRQ. List 5 complications of deep cervical
plexus block.

1. Phrenic nerve block - 60%. Do not use in patients with severe

respiratory disease or contralateral phrenic nerve palsy
2. Intravascular injection (vertebral artery runs 2-3mm from tip of
transverse processes)

3. Intrathecal injection - needle tip passing between transverse

processes
4. Horner’s Syndrome (Stellate ganglion C6-T1 block - ptosis, meiosis,
anhydrosis)
5. Recurrent laryngeal nerve palsy (bovine cough - inability to
adduct ipsilateral vocal cord) – risk of aspiration

25

CRQ. List the CNS monitoring options in CEA

1. Awake patient – fine motor/ consciousness

2. Transcranial doppler MCA
3. Stump Pressure (>40-50mmHg)
4. NIRS
5. Somatosensory Evoked potentials

26

13
SAQ. A CEA is being performed under LA.
A few minutes after clamping the carotid artery the
patient becomes unresponsive to verbal command.
Describe your management of the situation (40%)

 ~ 10% of CEA’s – 2oe to cerebral hypoperfusion

 ABC
 100% O2 via anaesthetic circuit FM
 Make sure BP is at or above awake levels
 Surgeon to insert shunt ASAP (Javed, Pruitt )
 Patient should regain consciousness
 Rarely GA may needed if patient unco-operative
 Remember the same will happen with removal of
shunt

27

Abdominal aortic aneurysm

“There is no disease more conducive to clinical humility
than aneurysm of the aorta”
William Osler 1905

28

14
AAA

 Incidence 4%
 Male (85%) > Female
 Strong family Hx
 SMOKING X 4-6
 Prevalence decreasing

 Cause – atherosclerosis + breakdown of the

 collagen – elastin matrix
 +/- inflammation and plasminogen activation
 Rare causes Marfan`s, TB, Takayasu

29

BMJ 1957;
Feb2nd:253-257

30

15
Since 2013 every man
in England
> 65 is offered
AAA screening

31

Aneurysm screening
1. No aneurysm (96%)
Aortic diameter < 3cm – no further Rx required
2. Small aneurysm (3.5%)
Aortic diameter 3 to 4.4cm – yearly surveillance
Aortic diameter 4.5 to 5.4cm – 3 monthly surveillance
3. Large aneurysm (0.5%)
– Aortic diameter > 5.5cm – vascular surgery
appointment

Screening has reduced mortality from rupture > 50%

32

16
% Yearly Risk of Rupture
25

20

15

10

0
<3.0 3 - 3.9 4 - 4.9 5 - 5.9 6 - 6.9 7 - 7.9
Size (cm)

33

AAA repair

 2008 VASCUNET UK open repair mortality 7.5 %

 AAAQIP 2012 aim to halve mortality rate

 NVR Report 2018 open repair mortality 3.2 %

 NVR Report 2018 EVAR mortality 0.4%

34

17
How do you decrease mortality?

 Better assessment

 CENTRALISATION

 More EVAR

35

Ratio of EVAR to Open

UK NVD 2006 to 2013

100%

80%

60%
EVAR
40%
Open

20% 2018
63% EVAR
37% Open
0%
2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13

36

18
Open AAA repair – 4 stages

1. Pre-clamping
2. Clamping
3. Post clamping
4. Post clamp release

37

1. Pre-clamping

 Incision: transverse T10 or midline

 Epidural (rectus sheath catheters)
 Art line / CVP
 Cardiac output monitor (ODM / LIDCO / NICOM Cheetah)
 Low volume low BP pre –clamping
 Heparin 5000 units - no ACT
 Warm upper body only

38

19
2. CVS effects of clamping

 Sudden increase in upper body SVR

 Lower body perfusion depends on collateral
circulation
 May increase BP/ myocardial strain / ischemia
 Effects unpredictable

39

3. Post clamping

 Slowly increase circulating volume

 Vasodilatation (volatile/ nitrates)
 Maintain BP -30%

 Wean vasodilators prior to release (BP> 110mmHg)

40

20
4. Clamp release

 Sudden drop in SVR - hypotension

 Return of ischemic metabolites H/K/CO2
 Ischemia reperfusion injury

 This requires GREAT communication

 between knife and gas
( and theatre staff )

41

Anaesthesia aims

 A warm, pain free, non acidotic, non coagulopathic, well

oxygenated, well filled patient.

 Hb > 90-100
 Routine cell salvage use
 No cross-match
 Early extubation

42

21
Renal protection

 Maintain Cardiac Output - avoid swings in BP. Minimise

blood loss

 Renal (incidence ARF 6.5%)

No evidence to support Dopamine
Furosemide
Mannitol
NAC
Sodium Bicarbonate 1.4%

[ischemia preconditioning, volatiles, propofol, dexmedetomidine, remifentanil]

43

Emergency AAA repair

 overall 75-90% mortality

 Post op ~ 40-50% mortality

 Transfer patient to vascular centre

Transfer to centre mortality 28%

Direct to centre mortality 34%

44

22
Emergency AAA Risk assessment tools

 Glasgow Aneurysm Scale  Hardman index

Age yrs +X Age > 76 1
Shock +17 HB < 90 1
IHD +7 Ischemic ECG 1
CVA +10 Hx loss of conc 1
CKD +14

Total 84 = 65% mortality Total 2+ = 80% mortality

45

Emergency AAA repair

 Rapid but realistic assessment

 Analgesia / oxygen
 Hypotensive resuscitation
 XM blood / platelets / FFP
 Cell salvage
 Art line / big drip / catheter
 Induction in theatre prep`ed and draped

46

23
Anaesthesia

 Induction - opiate / benzo / NMR / propofol (not ketamine /etomidate)

 ETT / NGT Aortic Clamp

 Pt is coagulopathic – no heparin
 Avoid hypothermia
 Thrombo-elastography / blood products
 Cardiac output monitor
 CVP before ICU

47

Clinical pearls

Pick your patients well

Pts die in theatre or of MOF on ICU
Intra-abdominal hypertension > 12 mmHg
IA Compartment syndrome >20mmHg
Treat coagulopathy aggressively in theatre
Blood products / TXA / Ca / Vit K / DDAVP

OR do an EVAR (IMPROVE Trial)

48

24
Does a policy of endovascular repair if feasible versus open repair influence
the 30 day outcomes from ruptured abdominal aortic aneurysm?

• At 30-days mortality & costs are similar in the 2 groups

• Women may benefit from an endovascular strategy
• More patients in the endovascular group get discharged directly to home
(& sooner) than the open repair group
• Re-interventions are similar in each group
• IMPROVE supports local anaesthetic infiltration as preferred technique for
rEVAR
• rEVAR is appropriate for higher risk patients if feasible without GA
• Permissive hypotension allowing systolic blood pressures < 70 mm Hg may
be hazardous
• Work required to deliver equitable outcome out of hours

49

Endovascular aneurysm repair - EVAR

◼ Less invasive alternative to open repair

◼ It can be performed under GA, RA or LA

50

25
Endovascular aneurysm repair - EVAR

• ~ 70% AAAs are anatomically

suitable for endovascular repair
– Neck length >10-15 mm
– Neck angulation < 45o
– Proximal neck diameter >30 mm
– Iliac artery diameter > 6mm

51

CRQ. List the advantages of EVAR.

Minimally invasive

Reduced blood loss

Reduced stress response

No cross clamp

Earlier ambulation

Shorter hospital stay

NOT cheaper

52

26
Neck 10 – 15 mm

53

Is EVAR better than open repair? – EVAR 1 trial

◼ 1082 patients (539 open repair v 542 EVAR)

◼ 30 day mortality is reduced 4.7% to 1.7% (65%
absolute reduction)1
◼ However early survival benefit v endograft related
complications – in particular endoleak - annual
surveillance
◼ Re intervention rates estimated at 5% per year
◼ Rupture rates as high as 1% per year despite EVAR
No long term EVAR survival benefit
1 Greenhalgh et al. Lancet 2005;365:2179-2186

54

27
Disadvantage of EVAR - Endoleak

55

There is no time when it is safe to discontinue

surveillance in patients who have had EVAR

56

28
EVAR 2

 Patients unfit for open surgery randomised to EVAR

or surveillance

 Short term EVAR benefit

 Again no long term survival benefit
 Pts die of co-morbidities

Caveat- both are old-ish data

57

Increased aneurysm related mortality after 8 years in

the EVAR group, mainly attributable to secondary
aneurysm sack rupture

58

29
Young and fit – Open or EVAR?

59

Anaesthesia for peripheral vascular surgery

Anaesthesia for lower limb revascularisation. BJA Education 2015 ; 5 : 225-30

60

30
Anaesthesia for peripheral vascular surgery

61

5 year survival CLI < 50%

claudication

CLI =Critical limb ischemia

62

31
PVD
• Elderly - 74% male
• Multiple co-morbidities
• (34% diabetic, 89% current or former smokers)
• 12 month post op mortality 17%
• Anaesthetic technique tailored to patient and co –
morbidities

63

Maintain MAP > 55mmHg

• Perioperative data for 33,330 non-cardiac surgeries at the Cleveland Clinic,

Ohio

• MAP less than 55 mmHg was associated with the development of AKI,
myocardial injury, and cardiac complications

64

32
 Endoscopic Thorascopic Sympathectomy

Palmar hyperhidrosis
Idiopathic 0.5-1%
Excessive sweating disproportionate to
thermoregulation
CRPS

Not for Raynaud`s

syndrome

65

Control of sweating

 1. eccrine glands (skin, feet, palms - watery)

 2. apocrine (axilla, areola, ear – oily)

SNS preganglionic = ACH(N)

SNS post ganglionic = adrenergic

EXCEPT sweat glands ACH (M)

T2-4

Stellate ganglion is C6-T1

66

33
67

Anaesthetic technique

 Double lumen tube one lung ventilation

 Single lumen tube small TV and
capnothorax
 Endoscope in 5th IC MAL + Ant AL
 Big drip
 Usually young and fit patient

68

34
Complications

 90% Compensatory sweating face / back/ trunk

 60% happy, 20% happy but sweaty, 20% unhappy
 Vascular injury: Subclavian vessels, Azygos (R), hemi
azygos (L) veins
 Capnothorax
 Pneumothorax
 Pulmonary injury
 Horner`s Syndrome

69

“ There are three stages of anaesthesia:

Awake, asleep and dead.
Try to aim for the middle one”

Richard Gordon 1969

Doctor in the House

70

35
Charles Eugster
Age: 97
World Record holder
Indoor M95 200m

“Life is movement “ - Aristotle 4th Century BC

71

72

36