Anesthesiology pp 607-614 | Cite as

Anaesthesia for Endovascular Aortic Aneurysm Repair (EVAR)

  • Milad Sharifpour
  • Salman HemaniEmail author


An aortic aneurysm is a localized dilatation greater than 50% of the original diameter. The normal size of the aorta is 2 cm; thus, an aneurysmal enlargement of three or more centimeters is an abnormal finding. Aneurysms occur in both the abdominal and thoracic cavities and are defined by their location. Approximately 80% of aortic aneurysms occur between the renal arteries and the aortic bifurcation (Aggarwal et al., Exp Clin Cardiol. 16:11–5, 2011). While they can be repaired by open surgical approach, minimally invasive endovascular approach has become the preferred surgical option in patients with suitable aortic anatomy. In the United States in 2010, approximately 78% of non-ruptured aneurysms were repaired by EVAR (Dua et al., J Vasc Surg. 59:1512–7, 2014). The rapid adaptation of vascular surgeons to endovascular techniques, as well as the advent of branched-fenestrated grafts, has notably increased the number of patients who undergo non-open aortic aneurysm repair. This chapter specifically focuses on the pre-operative evaluation, anesthetic management, and post-operative care of patients undergoing abdominal and thoracic endovascular aortic aneurysm repair.


EVAR TEVAR Abdominal aortic aneurysm Thoracoabdominal aortic aneurysm Contrast induced nephropathy Spinal cord ischemia Risk assessment for endovascular aortic aneurysm repair Revised cardiac risk index Endoleak 


  1. 1.
    Aggarwal S, Qamar A, Sharma V, Sharma A. Abdominal aortic aneurysm: a comprehensive review. Exp Clin Cardiol. 2011;16:11–5.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Harikrishnan K, Chieh GLH, Khan SA, Karthekeyan RB, Sharad SS. Anesthetic considerations for endovascular abdominal aortic aneurysm repair. Ann Card Anaesth. 2016;19:132–41.CrossRefGoogle Scholar
  3. 3.
    Dua A, Kuy S, Lee CJ, Upchurch GR, Desai SS. Epidemiology of aortic aneurysm repair in the United States from 2000 to 2010. J Vasc Surg. 2014;59:1512–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Greenhalgh RM, et al. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): randomized controlled trial. Lancet. 2005;365:2187–92.CrossRefGoogle Scholar
  5. 5.
    Greenhalgh RM, et al. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 1): randomized controlled trial. Lancet. 2005;365:2179–86.CrossRefGoogle Scholar
  6. 6.
    Crawford ES, Coselli JS. Thoracoabdominal aneurysm surgery. Semin Thorac Cardiovasc Surg. 1991;3:300–22.PubMedGoogle Scholar
  7. 7.
    Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, et al. 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary. J Am Coll Cardiol. 2014;64:2373–405.CrossRefGoogle Scholar
  8. 8.
    Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomized controlled trial. Lancet. 2008;371:1839–47.CrossRefPubMedGoogle Scholar
  9. 9.
    Flu WJ, van Kuijk JP, Chonchol M, Winkel TA, Verhagen HJ, Bax JJ, Poldermans D. Timing of pre-operative Beta-blocker treatment in vascular surgery patients: influence on post-operative outcome. J Am Coll Cardiol. 2010;56:1922–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Kertai MD, Bountioukos M, Boersma E, Bax JJ, Thomson IR, et al. Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery. Am J Med. 2004;116:8–13.CrossRefPubMedGoogle Scholar
  11. 11.
    Molnar AO, Coca SG, Devereaux PJ, Jain AK, Kitchlu A, et al. Statin use associated with a lower incidence of acute kidney injury after major elective surgery. J Am Soc Nephrol. 2011;22:939–46.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. J Am Coll Cardiol. 2016;68(10):1082–115.CrossRefPubMedGoogle Scholar
  13. 13.
    Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–9.CrossRefGoogle Scholar
  14. 14.
    Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces perioperative complications: a systematic review and meta-analysis. Am J Med. 2011;124:144–54.CrossRefPubMedGoogle Scholar
  15. 15.
    Grønkjær M, Eliasen M, Skov-Ettrup LS, Tolstrup JS, Christiansen AH, et al. Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. Ann Surg. 2014;259:52–71.CrossRefPubMedGoogle Scholar
  16. 16.
    Axelrod DA, Henke PK, Wakefield TW, Stanley JC, Jacobs LA, et al. Impact of chronic obstructive pulmonary disease on elective and emergency abdominal aortic aneurysm repair. J Vasc Surg. 2001;33:72–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Upchurch GR, Proctor MC, Henke PK, Zajkowski P, Riles EM, et al. Predictors of severe morbidity and death after elective abdominal aortic aneurysmectomy in patients with chronic obstructive pulmonary disease. J Vasc Surg. 2003;37:594–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Roger R, Bell RM, Hausenloy DJ. Contrast induced nephropathy following angiography and cardiac interventions. Heart. 2016;0:1–11. Scholar
  19. 19.
    Fishbane S. N-Acetylcysteine in the prevention of contrast-induced nephropathy. Clin J Am Soc Nephrol. 2008;3:281–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35:64–101.CrossRefPubMedGoogle Scholar
  21. 21.
    Kothandan H, Chieh GLH, Khan SA, Karthekeyan RB, Sharad SS. Anesthetic considerations for endovascular abdominal aortic aneurysm repair. Ann Card Anaesth. 2016;19:132–41.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    van Lier F, van der Geest PJ, Hoeks SE, van Gestel YR, Hol JW, et al. Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease. Anesthesiology. 2011;115:315–21.CrossRefPubMedGoogle Scholar
  23. 23.
    Bowers J, Ferguson JJ. The use of activated clotting times to monitor heparin therapy during and after interventional procedures. Clin Cardiol. 1994;17:357–61.CrossRefPubMedGoogle Scholar
  24. 24.
    Saratzis A, Melas N, Mahmood A, Sarafidis P. Incidence of acute kidney injury (AKI) after endovascular abdominal aortic aneurysm repair (EVAR) and impact on outcome. Eur J Vasc Endovasc Surg. 2015;49:534–40.CrossRefPubMedGoogle Scholar
  25. 25.
    Borthwick E, Ferguson A. Perioperative acute kidney injury: risk factors, recognition, management, and outcomes. BMJ. 2010;341:c3365.CrossRefPubMedGoogle Scholar
  26. 26.
    Fann JI, Mitchel RS, Kaiser C, Kee ST, Dake MD, van der Starre PJA. Vascular surgery. In: Jaffe RA, Schmiesing CA, Golianu B, editors. Anesthesiologist’s manual of surgical procedures. Philadelphia: Lippincott; 2014. p. 406–61.Google Scholar
  27. 27.
    Fok M, Mason A. The use of neuromonitoring in descending and thoraco-abdominal aortic aneurysm surgery: literature review. International Conference on Sensing Technology; 2014. p. 174–78.Google Scholar
  28. 28.
    Fok M, Jafarzadeh F, Sancho E, Abello D, Rimmer L, et al. Is there any benefit of neuromonitoring during descending and thoracoabdominal aortic aneurysm repair? Innovations (Phila). 2015;10:342–8.CrossRefGoogle Scholar
  29. 29.
    Shah A, Khoynezhad A. Thoracic endovascular repair for acute type A aortic dissection: operative technique. Ann Cardiothorac Surg. 2016;5:389–96.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of AnesthesiologyEmory UniversityAtlantaUSA

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