A meta-analysis of locoregional anesthesia versus general anesthesia in endovascular repair of ruptured abdominal aortic aneurysm

Splenic artery aneurysm with double-rupture phenomenon and circulatory collapse following anesthesia induction: A case report

BACKGROUND

Splenic artery aneurysm (SAA) rupture is a rare, life-threatening condition characterized by acute intra-abdominal hemorrhage and hemodynamic instability. Ruptured SAAs may exhibit a biphasic and relatively slow clinical progression, commonly referred to as the "double-rupture phenomenon". The reported incidence of the double-rupture phenomenon ranges 12%-21% in patients with ruptured SAAs, potentially due to variations in intra-abdominal pressure. Following anesthesia induction, muscle relaxation can decrease intra-abdominal pressure, potentially triggering the double-rupture phenomenon and leading to circulatory collapse.

CASE SUMMARY

A 61-year-old female presented to the Department of Emergency with upper abdominal pain, abdominal distension, dizziness, and vomiting. Her vital signs were initially stable. Physical examination revealed abdominal tenderness and positive-shifting dullness. Abdominal contrast-enhanced computed tomography revealed cirrhosis, severe portal hypertension, and splenomegaly. Acute rupture was suggested by a hematoma on the upper left side outside the SAA. Surgeons deemed intravascular intervention challenging and open splenectomy inevitable. Circulatory collapse occurred after anesthesia induction, likely due to a double rupture of the SAA. This double-rupture phenomenon may have resulted from an initial rupture of the SAA into the omental bursa, forming a hematoma that exerted a tamponade effect. A second rupture into the peritoneal cavity may have been triggered by decreased intra-abdominal pressure following anesthesia induction. The patient's life was saved through early, coordinated, multidisciplinary team collaboration. Following cardiopulmonary resuscitation and emergency splenectomy, she recovered without significant postoperative bleeding or hypoxic encephalopathy.

CONCLUSION

Anesthesia-induced pressure reduction may trigger a second SAA rupture, causing collapse. Early diagnosis and multidisciplinary teamwork improve outcomes. This is a rare and life-threatening case of SAA rupture, which is of great significance to the medical community for understanding and handling such emergencies.

A Systematic Review and Meta-Analysis of Local-Regional versus General Anesthesia for Elective Endovascular Abdominal Aortic Aneurysm Repair

Endovascular aneurysm repair (EVAR) is a minimally invasive treatment for abdominal aortic aneurysms. The choice between general anesthesia (GA) and local-regional anesthesia (LRA) may impact outcomes, but evidence remains inconsistent. This systematic review and meta-analysis aimed to compare GA and LRA in elective EVAR, focusing on mortality, major adverse cardiovascular events (MACE), endoleaks, intensive care unit admissions, and hospital stay (HS). A comprehensive search of PubMed, Embase, Cochrane Central, and ClinicalTrials.gov included studies from inception to December 2024. Observational studies meeting predefined criteria were analyzed using a fixed-effects model in R, and evidence certainty was assessed using the GRADE framework. This work was registered on PROSPERO (CRD42024547446). Seventeen studies with 91,560 patients were included. LRA was associated with reduced mortality (OR 0.75; 95% CI 0.59-0.97), lower MACE (OR 0.74; 95% CI 0.61-0.90), fewer intensive care unit admissions (OR 0.77; 95% CI 0.73-0.81), fewer type 1 endoleaks (OR 0.84; 95% CI 0.72-0.97), fewer type 2 endoleaks (OR 0.63; 95% CI 0.57-0.70), and shorter HS (-0.38 days; 95% CI -0.46 to -0.30). Sensitivity analyses confirmed most results, but mortality lost significance in some cases. The certainty of evidence ranged from low to very low due to some inconsistencies in studies. LRA may offer better outcomes than GA in elective EVAR, including lower mortality, MACE, and shorter HS. However, further randomized trials are needed to confirm these findings and guide clinical practice.

Endovascular aneurysm repair under local anesthesia through bilateral percutaneous femoral access is a safe strategy to improve early outcomes and reduce hospital stay

BACKGROUND

To estimate the impact of anesthetic conduct, alone and in combination with the type of femoral access, on early results after endovascular aneurysm repair (EVAR).

METHODS

A retrospective multicenter analysis on patients undergoing elective standard EVAR at four academic centers was performed. Patients undergoing the procedure through either local or general anesthesia were compared. Comparative subanalyses of the two groups were performed for the type of femoral access to evaluate further impact on outcomes.

RESULTS

Five hundred twenty-four patients underwent elective standard EVAR, of which 207 (39.5%) under general anesthesia and 317 (60.5%) under local anesthesia. Patients who underwent general anesthesia had higher 30-day mortality rates (3.4% vs. 0.3%, P=0.005), as well as slightly worse 30-day major systemic complication rates (8.2% vs. 5.4%, P=0.195). There were no differences in terms of reinterventions (2.1% vs. 2.5%, P=0.768) and aneurysm-related mortality (0% vs. 0.4%, P=0.422) at one year. Total intervention times were significantly longer in the general anesthesia group (126 vs. 89 minutes, P=0.001), as well as the total length of hospital stay (7.6 vs. 5.3 days, P=0.007). At subanalyses, the combination of local anesthesia with bilateral percutaneous femoral access further improved 30-day outcomes and determined an additional reduction in total intervention times and ICU stays.

CONCLUSIONS

EVAR performed under local anesthesia has a significantly better impact on early results when compared to general anesthesia. Combining percutaneous bilateral femoral access to local anesthesia reduced procedural times, ICU stays and consequently improved early results.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

General versus loco-regional anesthesia for endovascular aortic aneurysm repair

BACKGROUND

Aortic aneurysms occur when the aorta, the body's largest artery, grows in size, and can occur in the thoracic or abdominal aorta. The approaches to repair aortic aneurysms include directly exposing the aorta and replacing the diseased segment via open repair, or endovascular repair. Endovascular repair uses fluoroscopic-guidance to access the aorta and deliver a device to exclude the aneurysmal aortic segment without requiring a large surgical incision. Endovascular repair can be performed under a general anesthetic, during which the unconscious patient is paralyzed and reliant on an anesthetic machine to maintain the airway and provide oxygen to the lungs, or a loco-regional anesethetic, for which medications are administered to provide the person with sufficient sedation and pain control without requiring a general anesthetic. While people undergoing general anesthesia are more likely to remain still during surgery and have a well-controlled airway in the event of unanticipated complications, loco-regional anesthesia is associated with fewer postoperative complications in some studies. It remains unclear which anesthetic technique is associated with better outcomes following the endovascular repair of aortic aneurysms.

OBJECTIVES

To evaluate the benefits and harms of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repair.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was 11 March 2022.

SELECTION CRITERIA

We searched for all randomized controlled trials that assessed the effects of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repairs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were: all-cause mortality, length of hospital stay, length of intensive care unit stay. Our secondary outcomes were: incidence of endoleaks, requirement for re-intervention, incidence of myocardial infarction, quality of life, incidence of respiratory complications, incidence of pulmonary embolism, incidence of deep vein thrombosis, and length of procedure. We planned to use GRADE methodology to assess the certainty of evidence for each outcome.

MAIN RESULTS

We found no studies, published or ongoing, that met our inclusion criteria.

AUTHORS' CONCLUSIONS

We did not identify any randomized controlled trials that compared general versus loco-regional anesthesia for endovascular aortic aneurysm repair. There is currently insufficient high-quality evidence to determine the benefits or harms of either anesthetic approach during endovascular aortic aneurysm repair. Well-designed prospective randomized trials with relevant clinical outcomes are needed to adequately address this.

Local versus general anesthesia for endovascular aneurysm repair in ruptured abdominal aortic aneurysm: A systematic review and meta-analysis

OBJECTIVES/BACKGROUND

In the endovascular treatment of ruptured abdominal aortic aneurysm (RAAA), there is no effective evidence to show preference for a specific anesthetic option. A meta-analysis was conducted to assess the result of different anesthesia in endovascular aneurysm repair (EVAR) of RAAA.

METHODS

Randomized controlled trials (RCTs) and cohort studies were searched in PubMed, Embase, Ovid, and the Cochrane Library. Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool were applied to evaluate the quality of cohort studies and RCTs, respectively. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to express differences for primary and secondary outcomes. Subgroup analyses and sensitivity analyses were applied in the primary outcome to illustrate the results further. Significance was set at p < 0.05. Random-effects models were used considering limited research regardless of I²  < 50%.

RESULTS

Ten cohort studies were included in this meta-analysis. Perioperative mortality was presented as the primary outcome by analyzing eight of these research. Among the included patients, local anesthesia (LA) was considered as a better choice considering perioperative mortality (n = 156/902) rather than general anesthesia (n = 907/3434) with significant difference (OR: 0.49; 95% CI: 0.35-0.67; p < 0.00001; I²  = 42%). However, no significant difference was found in the secondary outcome: the complication rate, ICU admission rate, postoperative morbidity of pneumonia, myocardial infarction, leg ischemia, and wound complication.

CONCLUSIONS

There exists some evidence in this review that LA appears to improve perioperative mortality, especially in hemodynamically stable patients and should be recommended for patients undergoing EVAR with RAAA when appropriate.