Anesthetic Implications in Thoracic Endovascular Aortic Repair (TEVAR)
Fast-track anesthesia with early extubation is the preferred anesthetic approach for TEVAR procedures, as it significantly reduces ICU length of stay and overall hospital stay while maintaining patient safety.
Preoperative Considerations
Patient Assessment
- Evaluate cardiac function and comorbidities
- Review anticoagulation status and timing of last dose
- Assess vascular access sites for potential complications
- Review imaging to understand extent of aortic pathology
Monitoring Setup
- Arterial line placement is essential for continuous blood pressure monitoring
- Consider central venous access for vasopressor/inotrope administration
- Transesophageal echocardiography (TEE) should be available for emergency use during hemodynamic instability 1
Anesthetic Technique
Choice of Anesthesia
- General anesthesia with fast-track protocol is recommended for most TEVAR cases 2
- Consider starting with local anesthesia with sedation for emergency TEVAR, with option to convert to general anesthesia after stent placement 3
Induction and Maintenance
- Etomidate is the preferred induction agent (used in 93.1% of cases) to maintain hemodynamic stability 2
- Cisatracurium is the muscle relaxant of choice (98.5% of cases) 2
- Maintenance typically includes:
- Sevoflurane (85.3% of cases)
- Dexmedetomidine (98.5% of cases)
- Propofol (100% of cases) 2
Critical Hemodynamic Management
Blood Pressure Control
- Pre-deployment phase: Maintain permissive hypotension (systolic BP 90-100 mmHg) to reduce risk of aortic rupture 3
- Post-deployment phase: Shift to relative hypertension (MAP >80-90 mmHg) to optimize spinal cord perfusion 3
- Avoid rapid hemodynamic fluctuations throughout the procedure
Spinal Cord Protection Protocol
- Maintain MAP >80-90 mmHg after stent deployment
- Consider cerebrospinal fluid drainage to maintain adequate spinal cord perfusion
- Implement relative hypothermia
- Consider mannitol administration 3
Postoperative Management
Fast-Track Recovery
- Early extubation in hemodynamically stable patients 2
- Immediate transfer to post-anesthetic care unit with the following criteria:
- Core temperature ≥36°C
- Hemodynamic stability
- No active bleeding 1
Monitoring Requirements
- Continuous telemetry for at least 24 hours
- Regular neurological assessments to detect spinal cord ischemia (occurs in approximately 1.5% of cases) 2
- Monitor access sites for bleeding, hematoma, or pseudoaneurysm formation 1
Pain Management
- Multimodal analgesia with non-narcotic analgesics as first-line
- Avoid epidural analgesia in patients on anticoagulants or antiplatelet therapy 4
- Consider intercostal nerve blocks for access-site pain 1
Complication Management
Neurological Complications
- Spinal cord ischemia (1.5% incidence) and stroke (0.5% incidence) are the most common neurological complications 2
- Early detection through frequent neurological examinations
- Immediate intervention with blood pressure augmentation and CSF drainage if deficits occur
Vascular Complications
- Monitor for access site bleeding, hematoma, retroperitoneal bleeding
- Be prepared for vessel rupture with occlusion balloon and covered stents 1
Renal Protection
- Maintain adequate hydration
- Avoid early diuretic administration
- Monitor renal function with regular laboratory tests 1
Discharge Planning
- Early mobilization is critical for favorable outcomes
- Initiate structured discharge planning before the procedure
- Consider physical and occupational therapy assessment
- Early discharge (within 72 hours) is safe for uncomplicated transfemoral TEVAR 1
By implementing this comprehensive anesthetic approach focusing on fast-track protocols, meticulous hemodynamic management, and proactive complication prevention, patient outcomes following TEVAR can be significantly improved with shorter ICU stays and reduced hospital length of stay.