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….

8. Video time

10. 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

11. 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

12. 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

15. 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

16. 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

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

18. 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

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

20. 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.

21. Thanks for your attention!!