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AAA stent and anesthetic consideration

AAA stent and anesthetic consideration. Presented by 劉志中. Patient profile . 82y/o ,female Past history: 1.DM 2.HTN for 40 years 3.CAD ,two vessels (RCA,LCX) s/p POBAS 4.paroxysmal Af with RVR 5. left renal artery stenosis s/p stenting. Present illness.

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AAA stent and anesthetic consideration

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  1. AAA stent and anesthetic consideration Presented by 劉志中

  2. Patient profile • 82y/o ,female • Past history: 1.DM 2.HTN for 40 years 3.CAD ,two vessels (RCA,LCX) s/p POBAS 4.paroxysmal Af with RVR 5. left renal artery stenosis s/p stenting

  3. Present illness 2004/10 pulsatile abdominal mass ,echo and CT revealed AAA at 埔基 2004/11 came to NTUH an episode of chest tightness with ST-T depression and T inversion over V4-6 on ECG, Af with RVR s/p codarone control 2004/11 Cardiac cath:CAD,2VD s/p POBAS carotid duplex: bilateral carotid a. stenosis and vertebral a. flow insufficiency 2005/1/6 AAA stent

  4. Induction agent • Fentanyl 100ug • Atropine 0.5mg • Etomidate 18mg • Succinylcholine 70mg • Cistracurium 10 mg+ continuous infusion • NTG:0.1ml x 2

  5. Intraoperative mantainace • Sevoflurane • Intermittent bolus : fentanyl (total dosage:150ug)

  6. Op procedure • ETGA ,supine • Bilateral femoral a. cut-down and expose • L. femeral a. sheath insertion and put into a pig tail • R. femeral a. sheath insertion and put into the main body of AAA stent • Expended the stent….

  7. Video time

  8. What we have to know • Open vs. Stent graft • What kind of patients will we meet ? • Anesthetic plan • Intraoperative monitoring and surgical complications • Post operation care

  9. Open vs.Stent-graft • Open AAA repair is still the first choice of therapy currently • While aged patient ,increased co-morbidity, the cost and benefit of this traditional open surgery should be weighed

  10. An analysis of standard open and Endovascular surgical repair of AAA in Octogenarians • Endovascular surgical repair of AAA has the advantages as follows: 1. less blood loss 2. shorter ICU stay 3. shorter hospital stay 4. less blood transfusion 5. less cardiopulmonary complications The American surgeon 2003,Sep;744-748

  11. What kind of patients will we meet ? • The patient who presents for elective repair of an abdominal aortic aneurysm often has additional 1.hypertension (55%) 2.CAD (73.5%) 3.peripheral vascular disease (21%) 4.stroke and transient ischemic attack(22%) 5.DM(7%) 6.renal insufficiency (10%) 7.smoking history (80%) Vasc Surg 2001;35:335-44

  12. Anesthetic plan • General vs. regional No difference in overall cardiac and pulmonary morbidity and mortality J Vasc Surg 2002;36:988-91 • Appropriate monitoring :depends on patients coexisting disease. • Central venous access • Avoid cardiosuppression drugs as possible Anesthesiol Clin N Am,22(2004)251-64

  13. Intraoperative monitoring • Pulse oximetry • ECG (5 lead) • A- line • Foley • Temperature • CVP • PAP • TEE

  14. Surgical complications • Arterial injury ,device implant failed • Device occlusion,stenosis,migration • Endoleak 1.type I: inadequate seal at proximal of distal segments of the endoprosthesis 2.type II:brach flow through patent accessory renal,IMA,hypogastric,lumbar or sacral a. 3. type III: midgraft leak through a fabric hole or inadequate seal between graft components Anesthesiol Clin N Am,22(2004)319-32

  15. The risk of late failure is 3% per year, the continued presence of the risk of aneurysm rupture is 1% per year

  16. Post op care • Not routinely required ICU stay if uncomplicated • Prolonged mechanical ventilation may be indicated if major intra-op bleeding, MI,renal failure,bowel ischemia,sepsis syndrome,or ARDS. • Close hemodynamic monitoring • Adequate analgesia:opioid , NSAID,neuro-axial block. • Postimplantation syndrome: fever,leukocytosis,and increased CRP.

  17. Thanks for your attention!!

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