AAA open repair versus EVAR: anaesthetic decision matrix

Meet the patient

A 72-year-old smoker with a 6 cm infrarenal AAA and a 30-pack-year history is booked for elective open repair. He had a myocardial infarction two years ago. The surgeon plans a midline laparotomy with an infrarenal clamp. Before induction you confirm the arterial line, the large-bore access, the blood in theatre, and the cell salvage — because moment clamp goes on, this becomes a cardiac and vascular physiology problem, not a hernia.^[1]

Two questions frame every AAA list: can the heart stand the clamp and the unclamp? and is this elective open, elective EVAR, or a rupture? The answer decides the monitoring, the access, and the disposition.^[1]

References5ShowHide

1. [1]Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation, 1999.PMID 10477528
2. [2]Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet, 2008.PMID 18479744
3. [3]EVAR trial participants Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet, 2005.PMID 15978925
4. [4]Patel R, Sweeting MJ, Powell JT, Greenhalgh RM Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet, 2016.PMID 27743617
5. [5]Loggi S, Mininno N, Damiani E, et al. Changes in the sublingual microcirculation following aortic surgery under balanced or total intravenous anaesthesia: a prospective observational study. BMC Anesthesiol, 2019.PMID 30611197