EVAR (Endovascular AAA Repair)
Patient phenotype
60s–80s with infrarenal AAA ≥ 5.5 cm (or symptomatic/rapidly enlarging). Heavy comorbidity load: COPD, CAD, CKD, prior MI/CABG, diabetes. EVAR preferred over open in higher-risk patients given lower short-term mortality.
Procedure
Bilateral femoral artery access (cutdown or percutaneous), endograft deployed under fluoroscopy across aneurysm with proximal + distal seal zones. Hybrid OR. 1-3 hours. Contrast load substantial.
Anesthetic plan
Choice of GETA, neuraxial, or MAC + local. MAC + local increasingly used: lower hemodynamic insult, faster recovery, allows neuro check during deployment. GETA if patient cannot tolerate supine, has anxiety, or requires breath-hold for image quality.
Setup
- ·A-line — pre-induction always (renal artery + aortic positioning critical)
- ·Large-bore PIV (16g) + a second access
- ·Type & screen (low transfusion need but rupture conversion possible)
- ·Forced air warmer
- ·Foley with hourly UOP
- ·Open AAA conversion tray + setup ready in room
Biggest concerns by phase
CKD + contrast nephropathy
Contrast load 100-300 mL. Pre-hydrate with isotonic bicarbonate or NS (1 mL/kg/h × 6h pre + post). Hold metformin (lactic acidosis risk if AKI develops + contrast). Hold ACE/ARB morning of (intraop hypotension). N-acetylcysteine evidence weak — local protocol.
Cardiac optimization + beta-blockade
Continue chronic beta-blocker, statin, aspirin. New beta-blocker NOT initiated day-of (POISE harm). Cardiology stress test only if symptom change. ASA score III-IV typical.
Heparinization + ACT monitoring
Heparin 80-100 U/kg before sheath placement. ACT > 250 sec target before clamping/deployment. Recheck q30-60 min. Protamine reversal at end variable by surgeon.
Endoleak detection + arterial pressure during deployment
BP target SBP 100-120 during graft deployment to prevent migration + ensure seal. Some surgeons request brief hypotension (SBP 80-90) at deployment — esmolol or nitro bolus, avoid prolonged hypotension.
Distal embolization + lower extremity perfusion
Plaque dislodgement → trash foot, mesenteric ischemia, renal infarct. Check distal pulses + foot color before, during, after. Lactate trend matters.
Conversion to open repair — 1-3% incidence
Always be ready: rupture during deployment, inability to seal, access vessel injury. Rapid conversion = MTP, vasopressors, second A-line, blood in room. CRNA's job: anticipate + don't be caught short.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
78-year-old M for elective EVAR. EF 35%, COPD on home O₂, Cr 1.8 baseline. He's anxious. The team is debating GA vs MAC + local. Your input?
What an examiner probes for
- ▹Considers patient factors (anxiety, ability to lie flat, claustrophobia)
- ▹Weighs hemodynamic insult of GETA in low-EF + COPD
- ▹Discusses access for emergency conversion
- ▹Renal protective strategy (hydration, contrast minimization)
- ▹Makes a defended choice (often MAC with backup plan for GA)
Sources
- Miller's Ch 70
- SVS EVAR Guidelines 2018
- Stoelting/Hines Ch 16
Anatomy reference
Sourced reference images. 4 matches for "aorta abdominal arterial vascular".
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