JVS: Spinal/local anesthetics shorten EVAR length of stay
As endovascular repair techniques are poised to replace open surgical repair for abdominal aortic aneurysms (AAA), a study published in the November issue of the Journal of Vascular Surgery showed that using spinal and local anesthesia rather than general anesthetics may shrink post-op length of stay and limit post-operative complications, resulting in lower operative costs.

“Endovascular repair of abdominal aortic aneurysms (EVAR) was introduced in 1990 with the goal of offering a lower-risk alternative to traditional open surgical repair,” Matthew S. Edwards, MD, of the Wake Forest University School of Medicine in Winston-Salem, N.C., and colleagues wrote. “Over time, EVAR has been proven to reduce certain classes of morbidity and hospital length of stay, with conflicting results regarding reductions in early-term and long-term mortality rates.”

During the current study, Edwards et al assessed the outcomes of EVAR repair using anesthesia care (general, spinal, epidural and local/monitored anesthesia) from a multicenter U.S. hospital database that included 6,009 elective EVAR cases performed between 2005 and 2008. These EVAR cases were identified from the American College of Surgeons' National Surgical Quality Improvement Program database.

Of the 6,009 elective procedures included, general anesthesia was administered in 4,868 cases, spinal anesthesia in 419 cases, epidural anesthesia in 331 cases and local/monitored anesthesia was used in 391 cases. Patients had a median age of 74.1 years, 84 percent were male and the median length of stay was two days. The researchers reported the use of anesthesia during elective EVAR procedures. During the study period, 11 percent of the patients died; 30-day mortality was 1.1 percent.

The researchers reported that general anesthesia was also associated with an increase in pulmonary morbidity when compared with spinal anesthesia or local/MAC anesthesia. Local/MAC and spinal anesthesia techniques were able to reduce length of stay by 10 percent to 20 percent, respectively.

Additionally, these types of anesthetics were linked to a 60 to 75 percent decrease in the odds of acquiring a post-operative pulmonary complication, such as pneumonia and failure to get off the ventilator less than 48 hours post-surgery.

These complications greatly affect the costs of healthcare, the authors wrote. In fact, nosocomial pneumonia costs nearly $12,000 per occurrence, the authors noted.

“The anesthetic techniques used during EVAR varied widely across North America, with general anesthesia being the most common, by a large margin,” the authors wrote. However, general anesthesia was linked to a higher post-op pulmonary complication rate and a longer length of stay when compared with spinal and local anesthesia.

With the EVAR technique, the incision is made through the groin without aortic cross-clamping, unlike the open surgical approach. However, the authors noted that it remains undefined for which patient population this approach is most effective.

“Early reports from the investigational and European use of EVAR demonstrated the feasibility of nongeneral anesthesia and suggested locoregional anesthesia might have benefits,” the authors noted. Locoregional anesthesia can avoid mechanical ventilation and can permit the maintenance of spontaneous ventilation, minimizing a patient’s exposure to circumstances that increase the risk of post-op pulmonary failure.

“This report demonstrates clear benefits from the use of local/MAC and spinal anesthesia, but not epidural anesthesia, especially in relation to LOS [length of stay],” Edwards and colleagues noted. However, Edwards et al wrote that it is still uncertain as to why there are multiple differences in spinal and epidural anesthesia when compared with general anesthesia during EVAR procedures.

“These data support an increase in the use of local anesthesia/MAC or spinal anesthesia in EVAR patients suitable for such anesthetic approaches to reduce pulmonary morbidity and length of stay,” the authors concluded.