Endovascular Aortic Aneurysm Repair (EVAR) was introduced in the 1990s as a means to decrease the high morbidity associated with open aneurysm repair. Despite advancements in surgical technology and improved outcomes, little has changed in the anesthetic technique chosen. General anesthesia is still typically used EVAR, particularly when surgical cutdown of the access site is necessary. This case describes use of a neuraxial anesthetic for EVAR in a patient with an added risk of a known difficult airway secondary to symptomatic laryngeal cancer.
The patient was a 73-year-old male scheduled for urgent EVAR of a 10-cm infrarenal abdominal aortic aneurysm found incidentally during work-up of a symptomatic neck mass. Significant past medical history included newly diagnosed laryngeal cancer, peripheral vascular disease with claudication, and a 100-pack-year smoking history. Prior anesthetic records and imaging of the neck mass were unavailable.
Preoperative examination revealed a cachectic male with a quiet, raspy voice; 1x1cm right neck mass; SpO2 91% on room air; and no orthopnea. The patient also stated that over the last two months, he experienced progressive dysphagia and worsening cough. Airway instrumentation was deemed high risk for trauma, but because bilateral groin cutdowns were necessary for surgical exposure, the decision was made to proceed with neuraxial anesthesia. A combined spinal-epidural was performed supplemented by epidural lidocaine, with anxiolysis provided by dexmedetomidine, midazolam and fentanyl. The patient tolerated the procedure well and was discharged two days later
This case demonstrates a complex case requiring decisions balancing airway management and surgical requirements. A retrospective database analysis demonstrated decreased pulmonary morbidity and length of stay with neuraxial compared to general anesthesia in EVAR patients.1, 2 The case presented adds to the literature supporting neuraxial anesthesia for EVARs requiring surgical anesthetic conditions.
1. Edwards MS, Andrews JS, Edwards AF et al. Results of endovascular aortic aneurysm repair with general, regional, and local/monitored anesthesia care in the American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg. 2011;54(5):1273-82.
2. Horlocker TT, Wedel DJ, Rowlingson JC, 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.
