British Journal of Radiology (2005) 78, 62-64
© 2005 British Institute of Radiology
doi: 10.1259/bjr/13370263
Endovascular repair of a ruptured abdominal aortic aneurysm under local anaesthesia
J P Morales, MD1,
F G Irani, MBBS, MD1,
K G Jones, FRCS2,
P R Taylor, MA, MChir, FRCS2,
R Dourado, DCR1 and
T Sabharwal, MBBCH, FRCSI, FRCR1
Departments of 1 Interventional Radiology and 2 Vascular Surgery, Guy's and St Thomas' Hospital, London, UK
Correspondence: Dr Tarun Sabharwal, Consultant Radiologist, Department of Radiology, 1st Floor Lambeth Wing, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, UK
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Abstract
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Abdominal aortic aneurysm (AAA) is a common degenerative condition affecting the elderly population. Rupture carries a high overall mortality. Elective endovascular stent graft repair is well described. We describe a patient with ruptured AAA and co-morbid conditions making him unfit for surgery and general or epidural anaesthesia, who was successfully treated by endovascular stent graft under local anaesthesia.
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Introduction
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Abdominal aortic aneurysm (AAA) is a common degenerative condition affecting men three times more frequently than women [1]. There were 6800 deaths in England and Wales in the year 2000 from rupture of AAA [2]. The overall mortality rate from aneurysm rupture is in the order of 65–85% [3]. Of the deaths attributed to ruptured aneurysm, about half occurred before the patient reached hospital [4] and for those who survived the initial period; the mortality rate from emergency open surgical treatment was between 30% and 70% [3, 4].
Endovascular repair of AAA has evolved dramatically since it was first described in 1991 [5]. Elective endovascular repair of AAA is now an established procedure and given the potential to reduce morbidity and mortality associated with open surgical repair, endoluminal stenting offers therapeutic options to patients who are not surgical candidates due to their co-morbidities [6, 7].
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Case report
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A 71-year-old gentleman was admitted to a District General Hospital with pain in the abdomen and a tender partially irreducible right inguinal hernia. He had previously been diagnosed as having bilateral inguinal herniae and an asymptomatic infrarenal AAA, for which he refused treatment. During admission, the patient developed further abdominal pain, with a hypotensive episode and his haemoglobin fell from 15 gm% to 9 gm%. A clinical diagnosis of aortic aneurysm rupture was made. As he was haemodynamically stable, a CT scan was performed. The scan revealed an infrarenal suprailiac AAA with a maximum anteroposterior dimension of 6.5 cm. There was a large retroperitoneal haematoma extending into the pelvis, right scrotal sac and the right paracolic gutter. Active extravasation of contrast medium was noted from the left side of the aneurysmal sac (Figure 1
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Figure 1. Contrast enhanced CT scan showing an abdominal aortic aneurysm with retroperitoneal, right paracolic gutter haematoma and active extravasation of contrast (arrow).
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The patient was a known hypertensive on treatment. He had suffered from rheumatic fever in childhood and now suffered from arrhythmias and atrial fibrillation for which he was receiving Verapamil, Amiloride and Warfarin. He also suffered from chronic obstructive pulmonary disease (COPD) and carbon dioxide retention. In view of his high cardiopulmonary co-morbidities and abnormal coagulation profile, the patient was considered unfit for open surgery and general anaesthesia.
The appearance on CT suggested that the patient was suitable for endoluminal stent grafting (aneurysmal neck length 35 mm and favourable iliac arteries) and he was consequently transferred to our specialist vascular unit.
On arrival, the patient was drowsy, pale with a tender tense abdomen. His pulse rate was 80 beats per minute, blood pressure 108/60 mm Hg, haemoglobin of 9.0 gm%, oxygen saturation 97% on 2 l min–1 of oxygen with bilateral basal and right mid-zone crepitations. A coagulation profile revealed an international normalized ratio (INR) of 3.5 and activated partial thromboplastin time of 1.85.
It is our normal practice to insert aortic stent grafts under epidural or general anaesthesia. However in view of his deranged coagulation and co-morbid health state, particularly COPD, after obtaining informed consent, we performed the procedure under local anaesthetic (20 ml of 0.5% Bupivacaine hydrochloride, Astra Zeneca, Kings Langley, UK) and sedo-analgesia (Remifentanyl 10 µg ml–1 Ultiva; Glaxo Wellcome, London, UK and Propofol 1% Diprivan; Astra Zeneca). We chose to insert an aorto-bi-iliac endovascular stent graft. Two units of fresh frozen plasma were infused prior to the procedure, which was performed in the operating theatre using a Siemens Siremobil Iso-C Image Intensifier (Siemens AG, Erlangen, Germany).
Access was gained via common femoral arteriotomies. On table angiogram with a measuring catheter (5 F, Royal Flush® Plus Beacon® Tip Pigtail Angiographic Catheter; William Cook, Europe, Bjaeverskov) showed an infrarenal AAA without extension into the common iliac arteries (Figure 2) and extravasation of contrast from the sac (Figure 3).
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Figure 2. Early phase angiogram showing abdominal aortic aneurysm with a favourable 3.5 cm length infrarenal neck (arrows).
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An aorto-bi-iliac bifurcated Excluder endoprosthesis (WL Gore, Flagstaff, AZ) of size 23 mm x 160 mm x 95 mm was positioned and deployed infrarenally under fluoroscopy guidance using standard techniques.
Post deployment angiography showed complete exclusion of the aneurysmal sac, with no further extravasation of contrast medium (Figure 4) and preservation of both internal iliac arteries. Intraprocedurally the patient received 3000 IU of Monoparin® (heparin sodium 1000 units ml–1, CP Pharmacueticals, Wrexham, UK) and 1.2 g of Augmentin® (amoxiclav 1000/200, Glaxo Wellcome) intravenously. No immediate complications were noted and the total procedure time was 125 min.
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Figure 4. Post deployment angiogram showing stent graft in situ, with exclusion of aneurysm sac and leak.
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Following the procedure, the patient with his poor pulmonary reserve decompensated and became acidotic. He was transferred to the high dependency unit where he was closely monitored for 2 days. He received 2 units of packed cells and his haemoglobin remained stable. He was discharged after 3 days on the ward with a haemoglobin of 8.7 gm%.
On 6 month clinical follow up, the patient is alive and doing well, with no complaints related to his AAA.
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Discussion
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Following rupture of an AAA, only an estimated 38–64% of patients reach hospital alive [1]. Operative repair of ruptured AAA is associated with mortality rates between 25% and 60% [8].
AAA rupture can result in haemodynamic collapse and death before the patient reaches hospital. In slow ongoing contained leaks, the patient presents with abdominal pain, pulsating abdominal mass, falling blood pressure and haemoglobin.
The patient's risk of rupture from their AAA is increased if they also suffer with chronic obstructive airway disease, cardiac disease, stroke and aneurysm of size greater than 5 cm [7]. These same factors, in addition to malignancy, chronic renal failure, Parkinson's disease, dementia, co-existent severe acute pancreatitis and known thoracoabdominal extension of the aneurysm make patients unfit for surgery [8, 9]. The co-morbidities in our patient, not only made the aneurysm prone to rupture but also made him unfit for open surgery and general or epidural anaesthesia.
Endovascular repair of AAA is a minimally invasive procedure with a potentially reduced morbidity and mortality, as it avoids the need for surgical exposure of the aorta and aortic cross clamping [6, 10]. In addition, the use of endoprosthesis can considerably reduce the cardiac strain during the procedure as compared with open surgery and hence is particularly advantageous in high risk surgically unfit patients [11].
During the endovascular repair, the endograft is positioned within the aorta by a transfemoral or transiliac route to exclude the aneurysmal sac from the circulation, the graft being anchored by one or more metallic stents [6].
Experimental studies have shown that covered stents seal off the AAA immediately after stent placement, with gradual obliteration of the aneurysmal sac by collagen resulting in the reduced risk of further aneurysmal expansion and rupture [12].
The Registry of Endovascular Treatment of Abdominal Aortic Aneurysms (RETA) data have shown that only 30–50% of aneurysms are suitable for endovascular repair [10]. The procedure requires an accurate determination of aneurysm morphology with contrast enhanced CT or angiography. In symptomatic and ruptured AAA, a helical CT scan can rapidly assess the feasibility of endovascular treatment [10, 12]. This is provided that the patient is in a haemodynamically stable condition, as in our case.
The use of local anaesthesia with liberal sedation is an acceptable technique for endovascular aneurysmal repair because of its simplicity, reduced haemodynamic manipulation (in particular less vasopressor administration), reduced requirement for both intravenous fluid and subsequent monitoring and usage of ICU and hospital beds [11]. Further it provides a particular advantage in patients at high risk of cardiovascular complications and leaking aortic aneurysm since it does not change the haemodynamic situation in contrast to general anaesthesia [11, 13]. Bettex et al [11] in their study comparing the use of general, epidural and local anaesthesia for endovascular repair successfully used local anaesthesia in 63 of 91 patients, including four patients with ruptured aneurysms. The poor cardiopulmonary reserve in our patient made him unsuitable for general anaesthesia. The high INR made the patient unsuitable for epidural anaesthesia for fear of development of an epidural haematoma. For the moment, endoluminal repair of ruptured AAA, only seems applicable in selected haemodynamically stable unfit patients, as overall health status of patients and burden of co-morbid disease are important predictors of survival after endovascular repair [6, 9].
Whilst open surgical repair still remains the treatment of choice in haemodynamically unstable patients with ruptured AAA, we have demonstrated that endoluminal treatment under local anaesthesia in patients with raised INR can be successfully performed avoiding the complications of laparotomy, general and epidural anaesthesia, long hospital and intensive care stays.
Received for publication May 24, 2004.
Revision received August 12, 2004.
Accepted for publication October 1, 2004.
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References
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Abstract
Introduction
