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MIAMI BEACH – Both local anesthesia and regional anesthesia each surpassed general anesthesia for patients undergoing endovascular repair of an abdominal aortic aneurysm, significantly reducing procedure time, and significantly reducing postoperative hospitalization, Dr. Rutger A. Stokmans said at the 2012 International Symposium on Endovascular Therapy.
All three anesthesia types linked with similar rates of both technical and clinical success of the aneurysm repairs. Regional anesthesia also led to a significantly lower rate of ICU admission, compared with both general and local anesthesia; local anesthesia showed no significant difference for this measure, compared with general anesthesia.
Based on these findings, local or regional anesthesia should be preferred for EVAR, and general anesthesia should usually be avoided, said Dr. Stokmans, a vascular surgeon at Catharina Hospital, Eindhoven, the Netherlands.
These findings support the most recent anesthesia recommendations of the European Society for Vascular Surgery, which in 2011 guidelines for managing abdominal aortic aneurysms (AAA) cited local anesthesia as preferred for EVAR, with regional or general anesthesia reserved for patients with contraindications for local anesthesia, he said (Eur. J. Vasc. Endovasc. Surg .2011; 41[suppl. 1]:S1-S58). The most recent guidelines for AAA management from the Society for Vascular Surgery suggested using local or regional anesthesia over general anesthesia, he added (J. Vasc. Surg. 2009[suppl.];50:S2-S49).
But despite these recommendations, the most commonly used anesthesia type worldwide for EVAR repair of AAA has been general anesthesia, followed by regional anesthesia, with local treatment used least often, according to the registry data reported by Dr. Stokmans. Among the 1,199 patients enrolled in ENGAGE (Endurant Stent Graft Natural Selection Global Postmarketing Registry) during March 2009 to December 2010 in 30 countries on five continents, 749 (62%) underwent their EVAR with general anesthesia, 325 (27%) with regional, and 125 (10%) with local anesthesia. (Percentages do not add up to 100% because of rounding.)
The registry data also showed striking regional variations in anesthesia use, with general anesthesia used on about 90% of patients in Canada, Australia, and New Zealand, and on about 70% of patients in Scandinavian countries and the United Kingdom. But in Central Europe, regional anesthesia – used on nearly 70% of EVAR patients – dominated. The only region favoring local anesthesia was South America (Argentina, Columbia, and Uruguay), where about 50% of patients received local, but more than 40% received general anesthesia, he said. The registry contained no U.S. patients.
The average age of the EVAR patients was about 73 years. Those patients who underwent general anesthesia were significantly older, by an average of about 18 months, compared with those who received local or regional anesthesia.
The proportions of patients undergoing general, regional, or local anesthesia were similar in the subgroups of patients with American Society of Anesthesiologists (ASA) physical status scores of 1, 2, or 3. However, among the highest-risk patients included in the study – those with an ASA score of 4 – a significantly greater proportion of patients received general anesthesia. The multivariate models used in the analysis, therefore, were adjusted for age and for ASA score. About 42% of patients were in ASA class 2, and another 42% in class 3.
All patients were hemodynamically stable at the time of their enrollment. The maximum AAA diameter of registry patients was 6 cm, and about 88% of patients had an AAA diameter greater than 5 cm.
Average procedure times were 106 minutes in the general anesthesia patients, 95 minutes for regional, and 81 minutes for local – statistically significant differences among the three groups.
The average postoperative hospitalization was 5.2 days in the general anesthesia patients, 4.3 days in the regional patients, and 3.6 days in the local anesthesia patients, differences that were statistically significant among the groups.
The rate of technical surgical success was 98% in all three subgroups, and the rate of clinical success reached 97%-98% in all three groups. The rates of major adverse events during the 30 days following surgery were 5.1% in the general anesthesia patients, 3.2% in the local patients, and 2.2% in the regional anesthesia patients. None of these differences reached statistical significance. Major adverse events included death, MI, stroke, renal failure, blood loss greater than 1 L, and bowel ischemia. No patients developed paraplegia or respiratory failure.
Postoperative ICU admission occurred for 27% of the regional anesthesia patients, 35% of the general patients, and 42% of the local anesthesia patients. The rate among regional patients was significantly less than in the other two groups, but the difference in rates between the general and local anesthesia patients did not reach statistical significance.
The ENGAGE registry was organized and sponsored by Medtronic, which markets the Endurant stent. Dr. Stokmans and his associates received an unrestricted research grant from Medtronic.
Old habits die hard. It can be hard to keep up with the rapid transformation of a procedure that was traditionally near the top of the magnitude food chain and is now usually much more innocuous. This slow adaptation probably affects not just vascular surgeons but also anesthesiologists.
Although the report by Stokmans et al did not include cases from the U.S., it is consistent with the paper published last year by Edwards et al (J. Vasc. Surg. 2011;54:1273-82) based on experience from the NSQIP database. Pulmonary morbidity and LOS were significantly lower after local compared to general anesthesia without a mortality difference.
Ultimately, the choice of anesthetic for EVAR should be a collaborative decision between the surgeon and anesthesiologist after considering each individual clinical situation. However, the wide regional variation in anesthetic technique reported by Stokmans suggests that style of practice, perhaps independent of the individual clinical circumstance, is also a major determinant. These conclusions are being drawn from cohorts where only 5%-10% of patients received local anesthesia so the possibility of selection bias remains high.
Nonetheless, based on these two studies, vascular surgeons (and anesthesiologists) should pause and give more thought to this issue before they automatically opt for general anesthesia for their EVAR patients. Since EVAR is all about reducing the perioperative morbidity of AAA repair, choice of anesthetic should also be more consciously considered.
Dr. Larry W. Kraiss is professor and Chief of Vascular Surgery at the University of Utah, Salt Lake City and an associate medical editor of Vascular Specialist.
Old habits die hard. It can be hard to keep up with the rapid transformation of a procedure that was traditionally near the top of the magnitude food chain and is now usually much more innocuous. This slow adaptation probably affects not just vascular surgeons but also anesthesiologists.
Although the report by Stokmans et al did not include cases from the U.S., it is consistent with the paper published last year by Edwards et al (J. Vasc. Surg. 2011;54:1273-82) based on experience from the NSQIP database. Pulmonary morbidity and LOS were significantly lower after local compared to general anesthesia without a mortality difference.
Ultimately, the choice of anesthetic for EVAR should be a collaborative decision between the surgeon and anesthesiologist after considering each individual clinical situation. However, the wide regional variation in anesthetic technique reported by Stokmans suggests that style of practice, perhaps independent of the individual clinical circumstance, is also a major determinant. These conclusions are being drawn from cohorts where only 5%-10% of patients received local anesthesia so the possibility of selection bias remains high.
Nonetheless, based on these two studies, vascular surgeons (and anesthesiologists) should pause and give more thought to this issue before they automatically opt for general anesthesia for their EVAR patients. Since EVAR is all about reducing the perioperative morbidity of AAA repair, choice of anesthetic should also be more consciously considered.
Dr. Larry W. Kraiss is professor and Chief of Vascular Surgery at the University of Utah, Salt Lake City and an associate medical editor of Vascular Specialist.
Old habits die hard. It can be hard to keep up with the rapid transformation of a procedure that was traditionally near the top of the magnitude food chain and is now usually much more innocuous. This slow adaptation probably affects not just vascular surgeons but also anesthesiologists.
Although the report by Stokmans et al did not include cases from the U.S., it is consistent with the paper published last year by Edwards et al (J. Vasc. Surg. 2011;54:1273-82) based on experience from the NSQIP database. Pulmonary morbidity and LOS were significantly lower after local compared to general anesthesia without a mortality difference.
Ultimately, the choice of anesthetic for EVAR should be a collaborative decision between the surgeon and anesthesiologist after considering each individual clinical situation. However, the wide regional variation in anesthetic technique reported by Stokmans suggests that style of practice, perhaps independent of the individual clinical circumstance, is also a major determinant. These conclusions are being drawn from cohorts where only 5%-10% of patients received local anesthesia so the possibility of selection bias remains high.
Nonetheless, based on these two studies, vascular surgeons (and anesthesiologists) should pause and give more thought to this issue before they automatically opt for general anesthesia for their EVAR patients. Since EVAR is all about reducing the perioperative morbidity of AAA repair, choice of anesthetic should also be more consciously considered.
Dr. Larry W. Kraiss is professor and Chief of Vascular Surgery at the University of Utah, Salt Lake City and an associate medical editor of Vascular Specialist.
MIAMI BEACH – Both local anesthesia and regional anesthesia each surpassed general anesthesia for patients undergoing endovascular repair of an abdominal aortic aneurysm, significantly reducing procedure time, and significantly reducing postoperative hospitalization, Dr. Rutger A. Stokmans said at the 2012 International Symposium on Endovascular Therapy.
All three anesthesia types linked with similar rates of both technical and clinical success of the aneurysm repairs. Regional anesthesia also led to a significantly lower rate of ICU admission, compared with both general and local anesthesia; local anesthesia showed no significant difference for this measure, compared with general anesthesia.
Based on these findings, local or regional anesthesia should be preferred for EVAR, and general anesthesia should usually be avoided, said Dr. Stokmans, a vascular surgeon at Catharina Hospital, Eindhoven, the Netherlands.
These findings support the most recent anesthesia recommendations of the European Society for Vascular Surgery, which in 2011 guidelines for managing abdominal aortic aneurysms (AAA) cited local anesthesia as preferred for EVAR, with regional or general anesthesia reserved for patients with contraindications for local anesthesia, he said (Eur. J. Vasc. Endovasc. Surg .2011; 41[suppl. 1]:S1-S58). The most recent guidelines for AAA management from the Society for Vascular Surgery suggested using local or regional anesthesia over general anesthesia, he added (J. Vasc. Surg. 2009[suppl.];50:S2-S49).
But despite these recommendations, the most commonly used anesthesia type worldwide for EVAR repair of AAA has been general anesthesia, followed by regional anesthesia, with local treatment used least often, according to the registry data reported by Dr. Stokmans. Among the 1,199 patients enrolled in ENGAGE (Endurant Stent Graft Natural Selection Global Postmarketing Registry) during March 2009 to December 2010 in 30 countries on five continents, 749 (62%) underwent their EVAR with general anesthesia, 325 (27%) with regional, and 125 (10%) with local anesthesia. (Percentages do not add up to 100% because of rounding.)
The registry data also showed striking regional variations in anesthesia use, with general anesthesia used on about 90% of patients in Canada, Australia, and New Zealand, and on about 70% of patients in Scandinavian countries and the United Kingdom. But in Central Europe, regional anesthesia – used on nearly 70% of EVAR patients – dominated. The only region favoring local anesthesia was South America (Argentina, Columbia, and Uruguay), where about 50% of patients received local, but more than 40% received general anesthesia, he said. The registry contained no U.S. patients.
The average age of the EVAR patients was about 73 years. Those patients who underwent general anesthesia were significantly older, by an average of about 18 months, compared with those who received local or regional anesthesia.
The proportions of patients undergoing general, regional, or local anesthesia were similar in the subgroups of patients with American Society of Anesthesiologists (ASA) physical status scores of 1, 2, or 3. However, among the highest-risk patients included in the study – those with an ASA score of 4 – a significantly greater proportion of patients received general anesthesia. The multivariate models used in the analysis, therefore, were adjusted for age and for ASA score. About 42% of patients were in ASA class 2, and another 42% in class 3.
All patients were hemodynamically stable at the time of their enrollment. The maximum AAA diameter of registry patients was 6 cm, and about 88% of patients had an AAA diameter greater than 5 cm.
Average procedure times were 106 minutes in the general anesthesia patients, 95 minutes for regional, and 81 minutes for local – statistically significant differences among the three groups.
The average postoperative hospitalization was 5.2 days in the general anesthesia patients, 4.3 days in the regional patients, and 3.6 days in the local anesthesia patients, differences that were statistically significant among the groups.
The rate of technical surgical success was 98% in all three subgroups, and the rate of clinical success reached 97%-98% in all three groups. The rates of major adverse events during the 30 days following surgery were 5.1% in the general anesthesia patients, 3.2% in the local patients, and 2.2% in the regional anesthesia patients. None of these differences reached statistical significance. Major adverse events included death, MI, stroke, renal failure, blood loss greater than 1 L, and bowel ischemia. No patients developed paraplegia or respiratory failure.
Postoperative ICU admission occurred for 27% of the regional anesthesia patients, 35% of the general patients, and 42% of the local anesthesia patients. The rate among regional patients was significantly less than in the other two groups, but the difference in rates between the general and local anesthesia patients did not reach statistical significance.
The ENGAGE registry was organized and sponsored by Medtronic, which markets the Endurant stent. Dr. Stokmans and his associates received an unrestricted research grant from Medtronic.
MIAMI BEACH – Both local anesthesia and regional anesthesia each surpassed general anesthesia for patients undergoing endovascular repair of an abdominal aortic aneurysm, significantly reducing procedure time, and significantly reducing postoperative hospitalization, Dr. Rutger A. Stokmans said at the 2012 International Symposium on Endovascular Therapy.
All three anesthesia types linked with similar rates of both technical and clinical success of the aneurysm repairs. Regional anesthesia also led to a significantly lower rate of ICU admission, compared with both general and local anesthesia; local anesthesia showed no significant difference for this measure, compared with general anesthesia.
Based on these findings, local or regional anesthesia should be preferred for EVAR, and general anesthesia should usually be avoided, said Dr. Stokmans, a vascular surgeon at Catharina Hospital, Eindhoven, the Netherlands.
These findings support the most recent anesthesia recommendations of the European Society for Vascular Surgery, which in 2011 guidelines for managing abdominal aortic aneurysms (AAA) cited local anesthesia as preferred for EVAR, with regional or general anesthesia reserved for patients with contraindications for local anesthesia, he said (Eur. J. Vasc. Endovasc. Surg .2011; 41[suppl. 1]:S1-S58). The most recent guidelines for AAA management from the Society for Vascular Surgery suggested using local or regional anesthesia over general anesthesia, he added (J. Vasc. Surg. 2009[suppl.];50:S2-S49).
But despite these recommendations, the most commonly used anesthesia type worldwide for EVAR repair of AAA has been general anesthesia, followed by regional anesthesia, with local treatment used least often, according to the registry data reported by Dr. Stokmans. Among the 1,199 patients enrolled in ENGAGE (Endurant Stent Graft Natural Selection Global Postmarketing Registry) during March 2009 to December 2010 in 30 countries on five continents, 749 (62%) underwent their EVAR with general anesthesia, 325 (27%) with regional, and 125 (10%) with local anesthesia. (Percentages do not add up to 100% because of rounding.)
The registry data also showed striking regional variations in anesthesia use, with general anesthesia used on about 90% of patients in Canada, Australia, and New Zealand, and on about 70% of patients in Scandinavian countries and the United Kingdom. But in Central Europe, regional anesthesia – used on nearly 70% of EVAR patients – dominated. The only region favoring local anesthesia was South America (Argentina, Columbia, and Uruguay), where about 50% of patients received local, but more than 40% received general anesthesia, he said. The registry contained no U.S. patients.
The average age of the EVAR patients was about 73 years. Those patients who underwent general anesthesia were significantly older, by an average of about 18 months, compared with those who received local or regional anesthesia.
The proportions of patients undergoing general, regional, or local anesthesia were similar in the subgroups of patients with American Society of Anesthesiologists (ASA) physical status scores of 1, 2, or 3. However, among the highest-risk patients included in the study – those with an ASA score of 4 – a significantly greater proportion of patients received general anesthesia. The multivariate models used in the analysis, therefore, were adjusted for age and for ASA score. About 42% of patients were in ASA class 2, and another 42% in class 3.
All patients were hemodynamically stable at the time of their enrollment. The maximum AAA diameter of registry patients was 6 cm, and about 88% of patients had an AAA diameter greater than 5 cm.
Average procedure times were 106 minutes in the general anesthesia patients, 95 minutes for regional, and 81 minutes for local – statistically significant differences among the three groups.
The average postoperative hospitalization was 5.2 days in the general anesthesia patients, 4.3 days in the regional patients, and 3.6 days in the local anesthesia patients, differences that were statistically significant among the groups.
The rate of technical surgical success was 98% in all three subgroups, and the rate of clinical success reached 97%-98% in all three groups. The rates of major adverse events during the 30 days following surgery were 5.1% in the general anesthesia patients, 3.2% in the local patients, and 2.2% in the regional anesthesia patients. None of these differences reached statistical significance. Major adverse events included death, MI, stroke, renal failure, blood loss greater than 1 L, and bowel ischemia. No patients developed paraplegia or respiratory failure.
Postoperative ICU admission occurred for 27% of the regional anesthesia patients, 35% of the general patients, and 42% of the local anesthesia patients. The rate among regional patients was significantly less than in the other two groups, but the difference in rates between the general and local anesthesia patients did not reach statistical significance.
The ENGAGE registry was organized and sponsored by Medtronic, which markets the Endurant stent. Dr. Stokmans and his associates received an unrestricted research grant from Medtronic.
Major Finding: Postoperative hospitalization averaged 5.2 days in EVAR patients treated with general anesthesia, 4.3 days with regional anesthesia, and 3.6 days with local anesthesia.
Data Source: ENGAGE, an international registry of 1,199 patients who underwent EVAR for an abdominal aortic aneurysm during 2009 or 2010.
Disclosures: The ENGAGE registry was organized and sponsored by Medtronic, which markets the Endurant EVAR stent. Dr. Stokmans and his associates received an unrestricted research grant from Medtronic. Dr. Stokmans said that he had no other disclosures.