Effects of Anesthesia Type on Perioperative Outcome After Endovascular Aneurysm Repair

Abstract

Purpose: To examine outcomes of endovascular aortic aneurysm repair (EVAR) using general, regional, or local anesthesia. Methods: From March 2009 to April 2011, patients were enrolled from 79 sites in 30 countries worldwide and treated with an Endurant Stent Graft System. Data were compared among 3 groups based on the method of anesthesia: general anesthesia (GA) was used in 785 (62%) patients, regional anesthesia (RA) in 331 (27%) patients, and local anesthesia (LA) in 145 (11%) patients. Multivariate logistic regression analysis was performed to adjust for possible confounding factors; outcomes are presented as the odds ratio and 95% confidence interval. Results: There were intercontinental differences in the distribution of type of anesthesia used for EVAR. Higher ASA (American Society of Anesthesiologists) classification was associated with predominant use of GA. Procedure time was reduced in LA (80.4±40.0 minutes) compared with RA (94.2±41.6 min, adjusted p=0.001) and GA (105.3±46.0 minutes, adjusted p<0.001). Intensive care unit (ICU) admission was less frequent for RA than for GA (adjusted OR 0.71, 95% CI 0.53 to 0.97, p=0.030) and LA (adjusted OR 0.51, 95% CI 0.33 to 0.79, p=0.002). Postoperative hospital stay was significantly shorter for RA and LA compared with GA (adjusted p=0.003 and p=0.010, respectively). There were no significant differences in systemic and surgical complications. Mortality rates within 30 days did not differ among the groups. Conclusion: Type of anesthesia used during EVAR has no influence on perioperative mortality and morbidity. The use of local or regional anesthesia during EVAR appeared to be beneficial concerning procedure time, ICU admission, and postoperative hospital stay.

Keywords

abdominal aortic aneurysm endovascular aneurysm repair anesthesia outcome analysis local anesthesia

Introduction

Since the introduction of endovascular aortic repair (EVAR) in the 1980s, there have been substantial changes in the treatment of abdominal aortic aneurysms (AAAs).¹ With improved delivery technique and better technical features of the next-generation stent-grafts, EVAR shows lower intraoperative mortality and morbidity compared with the conventional open operation for AAA.^2–4

After 20 years, there is still no consensus about which type of anesthesia is most suitable for EVAR. Feasibility of local and regional anesthesia was proven in 1999.⁵ According to the guidelines of the European Society for Vascular Surgery, the preferential use of local anesthesia for EVAR is feasible and appears to be well tolerated, restricting regional or general anesthesia only to those with predefined contraindications for local anesthesia.⁶ The Society for Vascular Surgery practice guidelines suggest the use of epidural and local anesthetic along with conscious sedation for patients undergoing EVAR.⁷ However, these guidelines are based on a low level of evidence and recommendation.

The main objective of this study was to compare different anesthesia techniques in a real-world setting based on data retrieved from the prospective Endurant Stent Graft Natural Selection Global Post-Market Registry (ENGAGE) database.

Methods

Registry Design

The prospective, multicenter, nonrandomized ENGAGE Registry was undertaken to quantify the performance of the Endurant Stent Graft System (Medtronic, Santa Rosa, CA, USA) within the context of contemporary, real-world use. Ruptured AAAs were not eligible for the Registry, which was conducted according to the Declaration of Helsinki and the International Conference on Harmonization (ICH) Good Clinical Practice (GCP) guidelines. The Institutional Review Board at all participating sites approved the protocol, data collection, and analysis; informed consent for authorization of data release was obtained in all patients at the time of enrollment. Preexisting medical comorbidities and cardiovascular risk factors were recorded along with procedure and device information on web-based case report forms. Full methodological details of the ENGAGE Registry⁸ and of data collection⁹ were described previously. All of the data were reviewed, and more than 40% of patients’ source documentation was monitored randomly.⁸

Quality of life was assessed using the EuroQoL 5-Dimensions Questionnaire (EQ-5D) index score, a standardized instrument for use as a measure of health outcome in 3 different ways.¹⁰ The descriptive system has 5 dimensions (mobility, self-care, usual activity, pain/discomfort, and anxiety/depression) and 3 levels (no problems, some problems, extreme problems), which create 243 unique health states and can be converted into a single summary EQ-5D index (second measure) by applying scores from a set of general population preference weights. This study used the Dutch value set to calculate the EQ-5D index. The third measure was a 0 to 100 visual analogue scale (VAS) for self-rating of patient health. Ratings took place at the first contact (baseline), at discharge, and at the 30-day outpatient visit.

Definitions and Outcome Variables

Data about type of anesthesia were derived from operation and anesthesia reports. Local anesthesia (LA) was defined as infiltration of local anesthetics into the groin in combination or not with sedation. Spinal and epidural anesthesia were both defined as regional anesthesia (RA). If multiple anesthesia techniques were used, patients were assigned to the most invasive technique.

The primary outcome measure for the current analysis was 30-day morbidity and mortality. Secondary outcome measures included adverse events and quality of life. Technical success, procedure time, fluoroscopic time, volume of contrast, postoperative stay, and intensive care unit (ICU) admission were recorded. Initial technical success was defined as successful delivery and deployment of the Endurant endograft, without unintentional coverage of renal arteries, internal iliac arteries, or visceral branches, with absence of either a type I or III endoleak, followed by successful removal of the delivery system.¹¹ Duration of the implant procedure was defined as the time between cutdown or puncture and removal of the last guide catheter. Thirty-day complications included all-cause mortality, cardiac complications (cardiac death, myocardial infarction, cardiogenic shock, arrhythmia, other) bowel ischemia, neurologic complications (paraplegia, stroke), renal failure, respiratory failure, and surgical complications (access site, blood loss >1000 mL, conversion to open surgery). Thirty-day follow-up was completed for all patients.

Patient Groups

Excluding 2 patients who had missing anesthesia type, data were collected on 1261 patients (mean age 73.1 years; 1130 men) enrolled in the ENGAGE registry. Of these, 145 (11.5%) had LA, 331 (26.2%) had RA, and 785 (62.3%) had general anesthesia (GA). The GA group included 6 patients who scored both spinal and general anesthesia. Demographic data and baseline risk factors are presented in Table 1.

Table 1.

Baseline Characteristics According to Anesthesia Type.

Variables	General (n=785)^a	Regional (n=331)^a	Local (n=145)^a	p
Age, y	73.6±8.1	72.3±8.1	72.3±7.7	0.026
Gender				0.742
Male	706/785 (89.9)	293/331 (88.5)	131/145 (90.3)
Female	79/785 (10.1)	38/331 (11.5)	14/145 (9.7)
Baseline symptoms				0.004
Asymptomatic	679/785 (86.5)	267/331 (80.7)	112/145 (77.2)
Symptomatic	106/785 (13.5)	64/331 (19.3)	33/145 (22.8)
ASA classification				0.002
I	46/784 (5.9)	17/331 (5.1)	14/145 (9.7)
II	310/784 (39.5)	156/331 (47.1)	61/145 (42.1)
III	323/784 (41.2)	142/331 (42.9)	58/145 (40.0)
IV	105/784 (13.4)	16/331 (4.8)	12/145 (8.3)
Risk factors
Tobacco use	355/764 (46.5)	164/323 (50.8)	87/143 (60.8)	0.006
Hypertension	586/771 (76.0)	246/330 (74.5)	106/143 (74.1)	0.816
Hyperlipidemia	465/738 (63.0)	191/311 (61.4)	62/138 (44.9)	<0.001
Diabetes	161/772 (20.9)	56/327 (17.1)	19/144 (13.2)	0.060
Cancer	152/773 (19.7)	68/325 (20.9)	34/142 (23.9)	0.497
Cardiac disease
MI	205/754 (27.2)	82/314 (26.1)	31/141 (22.0)	0.435
Arrhythmia	128/768 (16.7)	52/321 (16.2)	18/144 (12.5)	0.457
Angina	121/764 (15.8)	52/324 (16.0)	19/145 (13.1)	0.681
CHF	39/761 (5.1)	23/322 (7.1)	9/145 (6.2)	0.418
CAD	261/756 (34.5)	124/318 (39.0)	37/143 (25.9)	0.023
Cardiac revascularization	216/770 (28.1)	94/328 (28.7)	27/145 (18.6)	0.049
Pulmonary disease	198/771 (25.7)	78/325 (24.0)	34/144 (23.6)	0.774
Renal insufficiency	119/778 (15.3)	49/327 (15.0)	22/145 (15.2)	0.991
Cerebrovascular disease	95/784 (12.1)	47/331 (14.2)	18/145 (12.4)	0.631

Abbreviations: ASA, American Society of Anesthesiologists; CAD, coronary artery disease; CHF, congestive heart failure; MI, myocardial infarction.

Continuous data are presented as the means ± standard deviation; categorical data are given as the counts/sample (percentage).

Statistical Analysis

Categorical variables are presented as frequencies (percentages); continuous variables are presented as mean ± standard deviation and/or median and interquartile range in the event of skewed data. Differences in baseline characteristics among the 3 study groups were analyzed using the chi-square test for discrete variables and the analysis of variance or the Kruskal-Wallis test for continuous variables. Multivariate logistic and linear regression analyses were used to adjust for possible confounding factors; multicollinearity was checked using the variance inflation factor and the tolerance. While p<0.05 was considered statistically significant for most analyses, the value was adjusted to p<0.017 for the regression analysis (Bonferroni correction) owing to multiple testing between groups. All statistical analyses were performed using SPSS software (version 20 for MAC; IBM Corporation, Somers, NY, USA)

Results

Baseline Characteristics

Patients were predominantly men, and the distribution of sexes was comparable between the groups. On average, there was an overall significant difference in age in GA, RA, and LA patients (Table 1, p=0.026). Distribution among the American Society of Anesthesiologists (ASA) classes was not equal (p=0.002); ASA class IV was associated with predominant use of GA (Figure 1). Symptomatic presentation was lower in LA and RA patients compared with GA patients (p=0.004). Risk factors, such as tobacco use, hyperlipidemia, coronary artery disease, and cardiac revascularization, were overall significantly different among groups (Table 1). Baseline aneurysm characteristics are summarized in Table 2. There were no significant differences in AAA diameter (p=0.449). Distal iliac fixation site diameters, proximal normal neck length, and angulation were significantly different among groups.

Table 2.

Baseline Aneurysm Characteristics.

Variable	General (n=785)^a	Regional (n=331)^a	Local (n=145)^a	p
Maximum AAA diameter, mm	60.5±11.9	60.1±10.6	59.3±12.6	0.449
Proximal neck diameter, mm	23.7±3.5	23.6±3.6	24.3±3.9	0.160
Proximal neck length, mm	27.5±12.5	26.8±12.6	24.7±11.0	0.045
Distal iliac fixation site diameter, mm
Right	14.4±3.6	14.0±3.7	13.4±3.0	0.017
Left	14.0±3.5	13.6±4.0	13.1±2.9	0.014
Infrarenal neck angle, deg	28.8±23.2	33.2±24.7	31.9±23.9	0.014
Suprarenal neck angle, deg	18.0±18.3	19.1±18.5	22.6±19.5	0.024

Abbreviation: AAA, abdominal aortic aneurysm.

Data are presented as the means ± standard deviation.

Intraoperative Outcomes

The mean adjusted procedure duration (Table 3) was significantly shorter in LA (80.4±40.0 minutes) compared to RA (94.2±41.6 minutes, adjusted p=0.001) and GA (105.3±46.0 minutes, adjusted p<0.001). There were no significant differences in type I and/or type III endoleaks at completion angiography among groups. Type of anesthesia used did not influence technical success rates. No intraoperative deaths occurred.

Table 3.

Procedure Data by Anesthesia Type.

Variable	General (n=785)^a	Regional (n=331)^a	Local (n=145)^a	GA vs RA	GA vs LA	RA vs LA
Variable	General (n=785)^a	Regional (n=331)^a	Local (n=145)^a	Adjusted p^b,c
Procedure time, min	105.3±46.0	94.2±41.6	80.4±40.0	0.002	<0.001	0.001
Contrast volume, mL	130.9±71.2	122.9±67.4	148.4±71.9	0.001	0.028	<0.001
Postoperative stay, d	5.2±5.4	4.3±4.8	4.0±3.6	0.003	0.010	0.731

				Adjusted OR^b,c (95% CI)
Admission to ICU	279/780 (35.8)	89/330 (27.0)	61/145 (42.1)	1.40 (1.03 to 1.90, p=0.030)	0.72 (0.49 to 1.05, p=0.091)	0.51 (0.33 to 0.79, p=0.002)
Type I endoleak	8/785	3/331	2/145	1.12 (0.28 to 4.52, p=0.879)	0.31 (0.06 to 1.74, p=0.185)	0.28 (0.04 to 1.93, p=0.197)
Type III endoleak	2/785	2/331	0/145	—	—	—
Intraoperative mortality	0 (0.0)	0 (0.0)	0 (0.0)	—	—	—
Conversion to open surgery	4 (0.5)	0 (0.0)	0 (0.0)	—	—	—
Technical success	767/785 (97.7)	322/331 (97.3)	142/145 (97.9)	1.01 (0.41 to 2.53, p=0.978)	1.06 (0.29 to 3.81, p=0.930)	1.05 (0.26 to 4.24, p=0.951)

Abbreviations: CI, confidence interval; GA, general anesthesia; ICU, intensive care unit; LA, local anesthesia; OR, odds ratio; RA, regional anesthesia.

Continuous data are presented as the means ± standard deviation; categorical data are given as the counts/sample (percentage).

Adjusted for age, baseline symptoms, ASA classification, tobacco use, hyperlipidemia, coronary artery disease, cardiac revascularization.

Level of significance for multiple testing: p<0.017.

Focusing on hospitalization, GA patients were significantly longer in the hospital than RA and LA patients (adjusted p=0.003 and p=0.010, respectively). GA and LA patients were admitted more frequently to the ICU than RA patients (GA vs RA: adjusted OR 1.40, 95% CI 1.03 to 1.90, p=0.030; RA vs LA: adjusted OR 0.51, 95% CI 0.33 to 0.79, p=0.002).

Mortality and Morbidity

Within 30 days after implant (Table 4), 11 (1.4%) GA patients died vs 3 (0.9%) RA patients (adjusted OR 1.52, 95% CI 0.41 to 5.65, p=0.534) vs 2 (1.4%) LA patients (adjusted OR 0.91, 95% CI 0.19 to 4.36, p=0.904). There were no significant differences for systemic or surgical complications.

Table 4.

Outcomes at 30 Days by Anesthesia Type.

Variable	General (n=785)^a	Regional (n=331)^a	Local (n=145)^a	GA vs RA^b	GA vs LA^b	RA vs LA^b
One or more complications	44 (5.6)	16 (4.8)	4 (2.8)	1.23 (0.65 to 2.31, p=0.529)	2.79 (0.84 to 9.29, p=0.094)	2.28 (0.63 to 8.18, p=0.207)
All-cause mortality	11 (1.4)	3 (0.9)	2 (1.4)	1.52 (0.41 to 5.65, p=0.534)	0.91 (0.19 to 4.36, p=0.904)	0.60 (0.10 to 3.75, p=0.598)
Cardiac complications
One or more cardiac sequelae	18 (2.3)	6 (1.8)	2 (1.4)	1.12 (0.42 to 3.01, p=0.818)	1.00 (0.21 to 4.65, p=0.997)	0.89 (0.17 to 4.69, p=0.889)
Cardiac death	6 (0.8)	1 (0.3)	1 (0.7)	2.74 (0.32 to 23.50, p=0.358)	0.94 (0.10 to 8.80, p=0.958)	0.34 (0.02 to 5.95, p=0.463)
Myocardial infarction	11 (1.4)	1 (0.3)	2 (1.4)	4.55 (0.56 to 36.70, p=0.155)	0.47 (0.09 to 2.48, p=0.376)	0.10 (0.01 to 1.27, p=0.104)
Cardiogenic shock	2 (0.2)	1 (0.3)	0 (0.0)	—	—	—
Arrhythmia	3 (0.4)	3 (0.9)	0 (0.0)	—		—
Other cardiac	2 (0.2)	1 (0.3)	0 (0.0)	—		—
Renal failure	3 (0.4)	1 (0.3)	0 (0.0)	1.74 (0.17 to 17.79, p=0.642)	—	—
Respiratory failure	0 (0.0)	0 (0.0)	0 (0.0)	—	—	—
Bowel ischemia	3 (0.4)	0 (0.0)	0 (0.0)	—	—	—
Neurologic				—	—	—
Paraplegia	0 (0.0)	0 (0.0)	0 (0.0)	—	—	—
Stroke	1 (0.1)	0 (0.0)	1 (0.7)	—	—	—
Surgical
Blood loss ≥1000 mL	16 (2.0)	2 (0.6)	0 (0.0)	3.28 (0.74 to 14.65, p=0.119)	—	—
Access site bleeding	7 (0.8)	3 (0.9)	1 (0.7)	0.76 (0.18 to 3.19, p=0.702)	1.02 (0.12 to 9.09, p=0.983)	1.36 (0.13 to 13.81, p=0.797)
Secondary intervention	10 (1.3)	7 (2.1)	2 (1.4)	0.77 (0.25 to 2.32, p=0.639)	1.02 (0.21 to 4.85, p=0.984)	1.32 (0.25 to 7.15, p=0.744)

Abbreviations: GA, general anesthesia; LA, local anesthesia; RA, regional anesthesia.

Continuous data are presented as the means ± standard deviation; categorical data are given as the counts (percentage).

Odds ratio (95% confidence interval) adjusted for age, baseline symptoms, ASA classification, tobacco use, hyperlipidemia, coronary artery disease, cardiac revascularization.

Activities of Daily Living and Quality of Life

Table 5 displays differences in quality of life data for the groups at each of the 3 time points (intergroup differences) and within each group from baseline to discharge and 30 days (intragroup differences). At baseline, quality of life and the dimensions of health status were similar in the 3 groups. At discharge, the LA group scored significantly better on usual activities and self-care. The change in EQ-5D index from baseline to discharge was negative in GA and RA patients (−0.06±0.22 and −0.03±0.17, respectively); no change was found in LA patients (0.00±0.19, p=0.006). After 30 days, there was an overall significant difference in VAS score among study groups (p=0.021) favoring LA patients. Changes in EQ-5D index from baseline to 30 days were positive for all groups and overall not significantly different (p=0.328).

Table 5.

Outcome of Activities of Daily Living and Quality of Life at 3 Time Points by Anesthesia Type.

Variable	General^a	Regional^a	Local^a	p
Baseline	n=750	n=327	n=130
Mobility				0.673
1 (no problem)	524 (69.9)	226 (69.1)	88 (67.7)
2 (some problems)	221 (29.5)	100 (30.6)	40 (30.8)
3 (extreme problems)	5 (0.7)	1 (0.3)	2 (1.5)
Self-care				0.953
1 (no problem)	676 (90.1)	299 (91.4)	117 (90.0)
2 (some problems)	64 (8.5)	25 (7.6)	11 (8.5)
3 (extreme problems)	10 (1.3)	3 (0.9)	2 (1.5)
Usual activities				0.848
1 (no problem)	596 (79.5)	267 (81.7)	107 (82.3)
2 (some problems)	134 (17.9)	53 (16.2)	21 (16.2)
3 (extreme problems)	20 (2.7)	7 (2.1)	2 (1.5)
Pain/discomfort				0.634
1 (no problem)	487 (64.9)	209 (63.9)	89 (68.5)
2 (some problems)	240 (32.0)	111 (33.9)	36 (27.7)
3 (extreme problems)	23 (3.1)	7 (2.1)	5 (3.8)
Anxiety/depression				0.201
1 (no problem)	551 (73.5)	231 (70.6)	92 (70.8)
2 (some problems)	181 (24.1)	85 (26.0)	30 (23.1)
3 (extreme problems)	18 (2.4)	11 (3.4)	8 (6.2)
VAS score of health (self-rated 0–100)	73.0±16.4	72.1±16.9	74.8±17.1	0.270
VAS score of health (self-rated 0–100)	75 (65–85)	75 (60–85)	80 (60–90)
EQ-5D index^b	0.84±0.21	0.84±0.20	0.82±0.22	0.492
	0.86 (0.78–1)	0.84 (0.78–1)	0.84 (0.77–1)
At discharge	n=641	n=285	n=118
EQ-5D index^b	0.78±0.22	0.81±0.19	0.81±0.17	0.128
	0.81 (0.69–1)	0.84 (0.73–1)	0.81 (0.78–1)
Change from baseline	–0.06±0.22	–0.03±0.17	0.00±0.19	0.006
	0.00 (–0.16 to 0.00)	0.00 (–0.12 to 0.00)	0.00 (–0.09 to 0.00)
After 30 days	n=646	n=282	n=125
EQ-5D index^b	0.85±0.19	0.85±0.19	0.86±0.19	0.978
	0.89 (0.81–1)	0.89 (0.78–1)	0.89 (0.81–1)
Change from baseline	0.08±0.21	0.05±0.17	0.04±0.17	0.328
	0.03 (0.00–0.16)	0.00 (0.00–0.16)	0.03 (0.00–0.16)

Abbreviation: EQ-5D, EuroQoL 5-Dimensions Questionnaire; VAS, visual analogue scale.

Continuous data are presented as the means ± standard deviation and median (interquartile range); categorical data are given as the counts (percentage).

A Dutch value set used to calculate EQ-5D index score.

Discussion

The effect of different anesthetic techniques in EVAR is described in small studies with possible selection bias. Unprecedented in size, scope, and geographic representation, the ENGAGE Registry represents the collective experience of 79 centers in 30 countries across 5 continents using a single stent-graft. Patients with a wide spectrum of comorbidities were included, resulting in a representation of everyday real-world clinical practice.⁸

According to the European and American guidelines, the use of local anesthesia for EVAR is preferred.^6,7 Despite this consensus, EVAR is still mainly conducted under GA,^12–15 as reflected in our study in which more than half the patients were treated under GA. However, there were large intercontinental differences for the primary choice of anesthetic (Figure 2). The differences between regions in Europe were even more remarkable. This could be explained by sustained regional customs of vascular surgeons and anesthesiologists. Another interesting finding is that patients in the GA group had a significantly higher ASA score, which is not according to the European guidelines.⁶ Unfortunately, the Registry did not foresee the need for a specific explanation on the individual choice of anesthesia, so we can only speculate on individual preferences.

In a cohort of 217 consecutive patients treated with a “local anesthesia–first strategy,” LA could be applied in ~75% of patients undergoing elective EVAR.¹⁶ Lachat et al¹⁷ published their first results of 100 consecutive patients treated percutaneously under local anesthesia in an outpatient setting, showing excellent results. Compared to the older EUROpean collaborators on Stent-graft Techniques for abdominal Aneurysm Repair (EUROSTAR) registry data,¹⁴ our analysis found a more frequent use of LA (11.5% vs 5.6%), which implies that LA is applied more commonly today.

EUROSTAR data indicated no differences in surgical outcome among types of anesthesia.¹⁴ Our results are consistent with these findings, showing comparable rates of technical success and endoleaks among the groups. In addition, no significant differences were seen in the need for secondary procedures within 30 days after implant.

LA and RA had shorter procedure times and hospital stays than GA.^12,14,18,19 In contrast to previous reports,^{13,14,18–21} the LA group had a remarkably higher requirement for ICU admission. This difference might be caused by 2 centers that had 100% ICU admission in 38 (26.2%) LA patients. When these groups were excluded, a significantly lower ICU admission rate emerged for LA (22.4%) compared with GA (35.8%; adjusted OR 0.55, 95% CI 0.33 to 0.91, p=0.020).

LA and RA are proven to be feasible and safe as an alternative for general anesthesia during EVAR.²² All-cause mortality rates were low in all 3 groups and were comparable with other studies.^14,15 There were no differences in short-term complications. There was a suggestion that LA might have fewer complications, but no significant advantage for LA was established, probably due to the low incidence of complications and its infrequent use. LA scored best on EQ-5D compared to RA and GA, which may imply that patients recover quicker after LA.

Bakker et al²³ described a significantly higher cardiac event rate at 30 days comparing general and locoregional anesthesia (OR 3.8, 95% CI 1.1 to 12.9, p=0.03). Despite a larger group of patients, there was no significant difference in cardiac event rates between general and locoregional anesthesia (OR 1.09, 95% CI 0.45 to 2.67, p=0.849) in the ENGAGE cohort.

The success of EVAR is highly dependent on AAA anatomy. Short and angulated infrarenal aortic necks increase the risk of type I endoleaks.²⁴ Complex AAA anatomy may also extend the duration of surgery, resulting in more discomfort for patients treated with locoregional anesthesia.²⁵ There was a shorter infrarenal neck length and a smaller iliac access diameter in the LA group. However, these differences were minimal and did not result in relevant differences in AAA complexity. LA may influence imaging quality because it is very dependent on patient movement and breath-holding ability during imaging.¹⁶ This could be an explanation why we found significantly more contrast use in the LA group.

General anesthesia might be preferred for extremely complex cases when there is a possibility of immediate conversion to open surgery. However, there was a low conversion rate of 0.3% in our study population. Furthermore, with an appropriate standby anesthetic team, conversion to GA is always possible.

Limitations

Unfortunately, preoperative clarification regarding the choice of anesthesia type is missing. Information regarding possible anesthesia type conversion was not documented. Therefore, no intention-to-treat analysis could be performed, and selection bias may have affected the results. The technique of femoral/iliac access was not documented. Percutaneous EVAR influences the amount of blood loss, operating time, and postoperative stay, possibly confounding results. Also, one has to take into account that the ENGAGE Registry was not designed nor powered for this specific retrospective analysis, restraining our findings.

Conclusion

The main findings of this study were that LA and RA had advantages compared with GA regarding duration of procedure and postoperative stay. No effects of anesthesia type on procedure success and perioperative mortality and morbidity were reported. Patients seemed to recover quicker after LA. Based on these results, a strategy based on preferential use of locoregional anesthesia for EVAR is advised, restricting GA only to those with predefined contraindications.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Joep A. W. Teijink, Philippe W. M. Cuypers, and Marc R. H. M. van Sambeek have received contributions and research grants from Medtronic AVE. Joep Teijink and Philippe Cuypers have been proctors for Medtronic AVE.

Funding

The author(s) report receiving the following financial support for the research, authorship, and/or publication of this article: Medtronic AVE funded the ENGAGE Registry. The Department of Vascular Surgery of the Catharina Hospital funded the writing of this article and was given access to the ENGAGE database to answer the study questions in this article.

References

Volodos

Shekhanin

Karpovich

. A self-fixing synthetic blood vessel endoprosthesis [in Russian]. Vestn Khir Im I I Grek. 1986;137(11):123–125.

Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005;365:2179–2186.

Lederle

Freischlag

Kyriakides

. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302:1535–1542.

Prinssen

Verhoeven

Buth

. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;351:1607–1618.

Henretta

Hodgson

Mattos

. Feasibility of endovascular repair of abdominal aortic aneurysms with local anesthesia with intravenous sedation. J Vasc Surg. 1999;29:793–798.

Moll

Powell

Fraedrich

. Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg. 2011;41(suppl 1):S1–S58.

Chaikof

Brewster

Dalman

. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009;50(4 suppl):S2–S49.

Stokmans

Teijink

Forbes

. Early results from the ENGAGE registry: real-world performance of the Endurant Stent Graft for endovascular AAA repair in 1262 patients. Eur J Vasc Endovasc Surg. 2012;44:369–375.

Bockler

Fitridge

Wolf

. Rationale and design of the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE): interim analysis at 30 days of the first 180 patients enrolled. J Cardiovasc Surg (Torino). 2010;51:481–491.

10.

Cavrini

Broccoli

Puccini

. EQ-5D as a predictor of mortality and hospitalization in elderly people. Qual Life Res. 2012;21:269–280.

11.

Chaikof

Blankensteijn

Harris

. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg. 2002;35:1048–1060.

12.

De Virgilio

Romero

Donayre

. Endovascular abdominal aortic aneurysm repair with general versus local anesthesia: a comparison of cardiopulmonary morbidity and mortality rates. J Vasc Surg. 2002;36:988–991.

13.

Parra

Crabtree

McLafferty

. Anesthesia technique and outcomes of endovascular aneurysm repair. Ann Vasc Surg. 2005;19:123–129.

14.

Ruppert

Leurs

Steckmeier

. Influence of anesthesia type on outcome after endovascular aortic aneurysm repair: an analysis based on EUROSTAR data. J Vasc Surg. 2006;44:16–21.

15.

Edwards

Andrews

Edwards

. 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;54:1273–1282.

16.

Geisbusch

Katzen

Machado

. Local anaesthesia for endovascular repair of infrarenal aortic aneurysms. Eur J Vasc Endovasc Surg. 2011;42:467–473.

17.

Lachat

Pecoraro

Mayer

. Outpatient endovascular aortic aneurysm repair: experience in 100 consecutive patients. Ann Surg. 2013;258:754–759.

18.

Bettex

Lachat

Pfammatter

. To compare general, epidural and local anaesthesia for endovascular aneurysm repair (EVAR). Eur J Vasc Endovasc Surg. 2001;21:179–184.

19.

Verhoeven

Cina

Tielliu

. Local anesthesia for endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2005;42:402–409.

20.

Ruppert

Leurs

Rieger

. Risk-adapted outcome after endovascular aortic aneurysm repair: analysis of anesthesia types based on EUROSTAR data. J Endovasc Ther. 2007;14:12–22.

21.

Asakura

Ishibashi

Ishiguchi

. General versus locoregional anesthesia for endovascular aortic aneurysm repair: influences of the type of anesthesia on its outcome. J Anesth. 2009;23:158–161.

22.

Karthikesalingam

Thrumurthy

Young

. Locoregional anesthesia for endovascular aneurysm repair. J Vasc Surg. 2012;56:510–519.

23.

Bakker

van de Luijtgaarden

van Lier

. General anaesthesia is associated with adverse cardiac outcome after endovascular aneurysm repair. Eur J Vasc Endovasc Surg. 2012;44:121–125.

24.

Stather

Wild

Sayers

. Endovascular aortic aneurysm repair in patients with hostile neck anatomy. J Endovasc Ther. 2013;20:623–637.

25.

Georgiadis

Trellopoulos

Antoniou

. Early results of the Endurant endograft system in patients with friendly and hostile infrarenal abdominal aortic aneurysm anatomy. J Vasc Surg. 2011;54:616–627.