What is the gold‑standard anesthetic management for infrarenal abdominal aortic aneurysm repair in an elderly patient with coronary artery disease, hypertension, and peripheral vascular disease?

Anesthetic Management for Infrarenal Abdominal Aortic Aneurysm Repair

For open infrarenal AAA repair in elderly patients with significant coronary artery disease, combined general anesthesia with thoracic epidural analgesia represents the optimal approach, with mandatory perioperative beta-blockade to reduce cardiac morbidity and mortality. 1

Preoperative Cardiac Optimization

Perioperative beta-adrenergic blocking agents must be administered in the absence of contraindications to reduce the risk of adverse cardiac events and mortality in patients with coronary artery disease undergoing AAA repair. 1 This is a Class I recommendation with Level A evidence from the ACC/AHA guidelines.

• Active cardiac conditions—unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease—must be identified and treated before elective repair 2
• Intermediate and high-risk patients should undergo non-invasive cardiac testing to determine whether preoperative medical optimization (beta-blocker, statin, aspirin) or interventional strategy (coronary angioplasty or cardiac surgery) is required 3
• Statin therapy should be initiated or optimized in all patients with atherosclerotic aortic disease to reduce cardiovascular events 2
• Strict blood pressure control is essential to minimize hemodynamic stress on the aneurysm and slow expansion 2

Anesthetic Technique Selection

For Open Repair

Combined general anesthesia with thoracic epidural analgesia is superior to general anesthesia alone, providing hemodynamic stability, reduced respiratory complications, and improved postoperative pain control. 3, 4

• Epidural analgesia decreases the risk of postoperative respiratory failure 3
• Thoracic epidural with 0.2% bupivacaine plus fentanyl 2.5 μg/mL provides effective preventive analgesia, though vigilance for hypotension (MAP <65 mmHg) is required 4
• Adequacy of Anesthesia (AoA) guidance should direct intraoperative rescue opioid administration to optimize hemodynamic stability while preventing inappropriate postoperative pain 4

Common pitfall: Thoracic epidural with ropivacaine may cause clinically significant hypotension despite adequate analgesia; bupivacaine-based solutions offer better hemodynamic stability 4

For Endovascular Repair (EVAR)

Local anesthesia is the preferred technique for EVAR when anatomically feasible, offering superior hemodynamic stability, reduced ICU utilization, and shorter hospital stays compared to general anesthesia. 5

• Local anesthesia for EVAR provides stable hemodynamics, significantly reduced vasopressor requirements (p<0.0002), and lower median fluid balance compared to general anesthesia 5
• ICU admission was required in only 27% of local anesthesia patients versus 70% with general anesthesia, with median hospital stay of 3 versus 5.5 days (p<0.0005) 5
• Regional anesthesia (single-dose spinal combined with epidural) is feasible and maintains stable arterial blood pressure throughout EVAR procedures 6
• General anesthesia remains appropriate when patient cooperation is limited or complex anatomic manipulation is anticipated 5

Intraoperative Hemodynamic Management

Invasive arterial monitoring is mandatory for open AAA repair to enable beat-to-beat blood pressure control and facilitate controlled phlebotomy if needed to optimize myocardial oxygen supply-demand balance. 7

• Avoid hypertensive episodes during intubation, surgical stimulation, aortic cross-clamping, and emergence to minimize wall stress 8
• Controlled phlebotomy can be employed intraoperatively to reduce preload and optimize myocardial stress in patients with significant stable CAD 7
• Perioperative myocardial ischemia should be monitored via continuous ECG and serial troponin I measurements 3

Surgical Approach Selection Based on Risk Profile

Women older than 75 years experience 90-day mortality exceeding 5% with open repair, making endovascular repair the preferred approach when anatomy permits. 2

• EVAR yields substantially lower 30-day mortality (≈1.7%) versus open repair (≈4.7%) in appropriate candidates 2
• CT angiography is required to assess EVAR suitability: proximal neck length ≥10-15 mm, neck diameter <30 mm, and adequate iliac access 2
• More than 50% of patients have anatomy unsuitable for standard EVAR; fenestrated or branched EVAR can expand treatment options 2
• Open repair remains appropriate for patients who cannot commit to lifelong EVAR surveillance or who lack suitable endovascular anatomy 1, 2

Critical caveat: Endovascular repair in patients at high surgical or anesthetic risk due to severe cardiac, pulmonary, and/or renal disease is of uncertain effectiveness (Class IIb recommendation) 1

Renal Protection Considerations

No pharmacological treatment has proven efficacy in decreasing acute renal failure after aortic surgery; focus on maintaining adequate perfusion pressure and avoiding nephrotoxic contrast when possible. 3

• Postoperative renal dysfunction (doubling of creatinine or dialysis requirement) independently predicts poorer short- and long-term survival 2
• Renal dysfunction increases the incidence of respiratory failure, spinal cord injury, and cardiac complications 2

Postoperative Management

Continue beta-blocker therapy postoperatively if initiated preoperatively, and maintain strict blood pressure control during recovery. 1, 8

• Epidural analgesia should be continued for 48-72 hours postoperatively to optimize pain control and reduce pulmonary complications 3, 4
• Systemic morphine serves as rescue analgesia when Numeric Pain Rating Score exceeds 3 4
• Early mobilization on postoperative day 1 is the goal, particularly after EVAR under regional or local anesthesia 6