Reversal agents for dabigatran and xabans
Dabigatran: Idarucizumab
Rivaroxaban/ apixaban: Andexanet
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List the advantages and disadvantages of local, regional, and general anaesthesia management for endovascular aneurysm repair (EVAR).
✅** Local Anaesthesia**
Advantages:
* Avoids airway manipulation and mechanical ventilation.
* Reduced cardiopulmonary stress (ideal for high-risk patients).
* Shorter recovery time and ICU stay.
* Lower incidence of postoperative delirium.
Disadvantages:
* Limited control if patient becomes restless or anxious.
* Inadequate analgesia for prolonged or complex procedures.
* Conversion to GA may be required in emergencies.
* Patient discomfort during sheath insertion or balloon inflation.
✅ Regional Anaesthesia (e.g., Epidural/Spinal)
Advantages:
* Good analgesia and patient comfort.
* Reduced stress response compared to GA.
* Avoids airway instrumentation.
* Awake patient can cooperate with periods of cessation of breathing.
* Facilitates early mobilization.
Disadvantages:
* of hypotension and sympathetic blockade.
* Technical difficulty in anticoagulated patients.
* Limited duration for long procedures.
* Potential for high block or spinal complications.
✅ General Anaesthesia
Advantages:
* Complete patient immobility and comfort.
* Easier control of ventilation and oxygenation.
* Better management of unexpected complications (e.g., rupture).
* Allows use of TEE and invasive monitoring.
Disadvantages:
* Increased cardiopulmonary stress (especially in elderly/high-risk).
* Longer recovery and ICU stay.
* Higher risk of postop delirium and pulmonary complications.
* Requires airway instrumentation.
References:
Miller’s Anaesthesia, 9th ed.
BJA review: “Anaesthetic considerations for EVAR”
Anaesthesia & Analgesia: “Regional vs General Anaesthesia for EVAR”
* SAJAA perioperative vascular surgery guidelines
Def of aortic aneurysm
Dilatation o the aorta >1.5X normal size, affecting any part of the aorta
a) What is his annual risk of rupture and why is this important?
a) Risk depends on aneurysm size:
<5.5 cm: ~1–5% per year.
≥5.5 cm: ~10% per year.
≥7 cm: >30% per year.
Why important?
Guides urgency of repair: Larger aneurysms have exponentially higher rupture risk, which outweighs perioperative risk.
Informs shared decision-making and timing of EVAR vs surveillance.
Preop
Patient factors: Elderly, comorbidities (CAD,COPD, HPT, Atherosclerosis, CKD etc ).
Procedural urgency: Emergency very high risk
Procedural risk
Assessment : comprehensive physical assessment inc neurological assessment and CVS risk stratification
**Investigations: **
Preparations: BP control, smoking cessation, medication adjustment
Anticipate procedure specific risks
Consent inncludes open surgical repair
Intraop
Remote location plus radiation exposure
**Monitoring:* ** Invasive BP, large-bore IV access, ECG with cont ST monitoring . TEE
Long duration: Spinal cord & CSF monitoring
Access and positioning: Groin exposure, avoid hip flexion.
Blood pressure control: Maintain proximal perfusion during stent deployment; avoid severe hypotension.
Renal protection: Minimize contrast load, maintain hydration, avoid nephrotoxins.
Spinal cord perfusion: Maintain MAP >80 mmHg post-deployment.
Plan for conversion to open repair: Prepare for rapid induction and cross-clamp physiology.
Choice of anaesthesia: Local/regional for high-risk patients; GA for complex cases or anticipated conversion.
c) Name risk factors for spinal cord ischaemia and how would you try to prevent it?
**c) Risk factors for spinal cord ischaemia **
1. Extensive coverage of thoracic/abdominal aorta. Supra-renal EVAR and complex EVAR
2. Occlusion of intercostal or hypogastric arteries.
3. Prolonged hypotension.
4. Previous aortic surgery.
55. Emergency surgery
Prevention:
Maintain high MAP (>80–90 mmHg).
Intraop neuromonitoring
Avoid hypothermia. ( Contributes to coagulopathy and increases blood viscosity, reducing perfusion)
Consider CSF drainage in high-risk cases.
Stage procedures if possible.
Open surgical repair: Limit clamp time, progressive unclamping- post conditioning, partial left eart bypass
What is the 2-peak patter?
The ** 2-peak pattern** describes a biphasic (2 phase) clinical or biochemical response seen after ischaemia-reperfusion injury, especially involving neutrophil activity, cytokine release or organ injury markers.
1st peak: minutes to 2hours. Due to **direct effects **of ischaemia and reperfusion (e.g. oxidative stress, cell swelling)
2nd peak: 6-24 hours later. Caused by inflammatory response- neutrophil infiltration, cytokine storm, complement activation
Why important?
1st peak is often inevitable, due to surgical or traumatic insult.
2nd peak can be modulated or prevented by interventions like:
* Corticosteroids
* Iscahemic preconditioning
* Neutrophil inhibitors
* CSF drainage in aortic surgery
Risk factors for AKI in EVAR surgery
- Age > 70 years
- Diabetes mellitus
- Cardiac failure
- Preop eGFR <60Ml/min (CKD stage3a an above)
- Preop dehydration
- ACE inhibitor/ ARB therapy
- Periop administration of aminoglycosides/diuretics
- Repeat exposure to IV contrast within 7 days
- Complex EVAR i.e. fenestrated/ chimney/ branched graft (greater volume of IV contrast used intraoperatively).
Complications following EVAR
- Early and short term complications
Conversion to open
Arterial rupture or dissection. Highest risk is during stent deployment
Plaque rupture and embolisation
Ischaemia of bowel, kidneys, or buttocks/legs from prolonged femoral/ iliac artery occlusion
Spinal cord ischaemia
Post-implatation syndrome : self limiting non infectious rise in temp, WCC and CRP due to endothelial reaction
Long term Cx
Endoleak (5 subtypes)
Infection
Graft migration
Delayed rupture
