E.S. Choi2, F.F. Aziz3, A. Zil-E-Ali1, F. Aziz1 1Penn State University College Of Medicine, Department Of Vascular Surgery, Hershey, PA, USA 2Penn State University College Of Medicine, Hershey, PA, USA 3University Of Michigan, Ann Arbor, MI, USA
Introduction: Endovascular Aortic Repair (EVAR) is considered the operation of choice for both symptomatic and asymptomatic abdominal aortic aneurysm (AAA) who meet the anatomic criteria. This study aimed to compare outcomes of EVAR in patients with symptomatic AAA performed under general anesthesia (GA) to those who undergo this operation under local anesthesia (LA). While some studies suggest that local anesthesia may be favorable over general, our study provides a comparison of primary outcomes with sub-analyses and a comprehensive set of secondary outcomes for both symptomatic and asymptomatic EVARs.
Methods: We used the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) Database to select patients who underwent EVAR from 2003 to 2021. We grouped the EVAR procedures done for symptomatic AAAs into non-ruptured and ruptured and then further grouped by anesthesia type (LA and GA). Our primary outcomes were 30-day mortality, in-hospital mortality, length of stay, and discharge disposition. The secondary outcomes included ICU stay, cardiovascular outcomes (myocardial infarction, dysrhythmia, CHF, stroke, and MACE), pulmonary complications (respiratory status and pneumonia), and renal complications (creatine levels and dialysis status).
Results: 8,710 patients underwent EVAR for symptomatic disease in this study. They were stratified into two categories: Non-ruptured (n= 5,310) and Ruptured (n= 3,400). Of the 5,130 Non-ruptured EVARs, 6.2% were under LA and 93.8% were under GA. Of the 3,400 Ruptured EVARs, 13.4% were under LA and 86.6% were under GA. Ruptured EVARs had a difference compared to Non-ruptured EVARs with anesthesia type for outcomes including: 30-day mortality (Ruptured LA 12.3%, Ruptured GA 20.5%, OR [0.50 (0.34 – 0.72)], p<0.001) and in-hospital mortality (Ruptured LA 10.3%, Ruptured GA 19.1%, OR [0.42 (0.28 – 0.63)], p<0.001). There were no differences in secondary outcomes for non-ruptured EVARs based on anesthesia type; however, there were several in ruptured EVARs: ICU stay ICU stay (Ruptured LA 3.6 ± 5.2, Ruptured GA 4.9 ± 7.2), dysrhythmia (Ruptured LA 9.0%, Ruptured GA 12.4%), and stroke (Ruptured LA 0.0.9%, Ruptured GA 2.4%). LA compared to GA in non-ruptured and ruptured EVARs did not result in a difference in renal complications.
Conclusion: There is an increased risk of peri- and post-operative risk in patients undergoing EVAR or ruptured aneurysms regardless of anesthesia type (local vs. general) compared to unruptured aneurysms. Our study demonstrates that there is an increased overall burden for ruptured EVARs even with mitigation of local anesthesia use.