Anaesthesia for endovascular aneurysm repair

Surgical repair of abdominal aortic aneurysms (AAA) can be done via an open or endovascular approach; surgical and patient factors determine which is most appropriate. Endovascular aneurysm repair (EVAR) is usually done in specialist centres with a multidisciplinary team involving surgeons, interventional radiologists and anaesthetists. Benefits of this approach include reduced physiological insult, shorter hospital stays and more favourable early mortality but it also requires lifelong follow-up, and mortality in the mid to long term is no better than open repair (OR). As a result, there was initial hesitancy by the UK National Institute for Health and Care Excellence to recommend EVAR in elective AAA repair but this was revised and can now be considered where open repair is contraindicated. Indeed, the majority of elective AAA repair is done endovascularly. Patients undergoing EVAR are usually more comorbid and frailer than OR patients and so comprehensive preoperative assessment and optimization is paramount. The often-remote location of, and associated radiation exposure in hybrid theatres can present additional challenges to the anaesthetist. General, regional or local anaesthesia can be employed, each with associated benefits and disadvantages. Intraoperative management can vary depending on patient, anaesthetic and surgical factors. Specific considerations include providing a balance between the potential for significant blood loss whilst also requiring a level of anticoagulation, the physiological changes around stent deployment and facilitating optimal imaging. Postoperatively complications are usually minimal but patients require lifelong follow-up, making it a more intrusive and expensive option compared to OR.