Thoracic Endovascular Aortic Repair (TEVAR)
Moderator: E. Andrew Ochroch, MD
Challenges of Postoperative Management, ICU Care
Jacob T. Gutsche MD
Assistant Professor
University of Pennsylvania
Philadelphia, Pa
Objective:
Participants will gain knowledge of the peri-operative management challenges with a focus on ICU
management after TAA repair.
TEVAR is now considered a reasonable alternative to open repair of thoracic aortic aneurysms (TAA).
Patients undergoing TEVAR tend to be elderly with multiple comorbidities which may increase the risk of
post-operative morbidity and mortality. Complications associated with TEVAR include death, stroke,
paralysis due to spinal cord ischemia, respiratory failure, renal insufficiency, and vascular complications.
The incidence of major complications associated with TEVAR range from 10-12% in the 30-day postoperative period.(1) A thorough understanding of the technical aspects of the surgery and the
associated risks is important to develop care guidelines to limit risk of these complications. In addition,
monitoring and rapid diagnosis of complications can facilitate therapy delivery to increase the possibility
of recovery.
Stroke is a common complication ranging from 2.5-3.6% in modern trials, but has been reported to be as
high as 8% in other series.(1) The majority of strokes attributed to TEVAR are a result of atheroemboli
from manipulation of the aortic arch with wires and delivery devices.(2) Despite this, an emergent
computed tomography(CT) scan should be performed to rule out a hemmorhagic stroke. Furthermore, a
large stroke may be diagnosed and may change management because of the higher risk of conversion to
hemmorhagic stroke. As such, the treatment of atheroembolic stroke is not amenable to thrombolytic
therapy. Management of acute post-operative stroke is mostly supportive includes permissive
hypertension, serum glucose control, maintaining normothermia, optimizing the head of bed
position.(3) Patients who are able to maintain oxygenation, have a low risk for aspiration, and low
suspicion for elevated intracranial pressure should be maintained in supine position.(4)
The risk of spinal cord ischemia ranges from 3-11%. Lumbar drain and hemodynamic management to
minimize the risk of paralysis will be discussed by Dr. Fedorow.
Post-operative renal insufficiency following TEVAR is associated with worse outcome including stroke,
myocardial infarction, and paraplegia.(5) Pre-operative renal insufficiency has been shown to increase
the risk of converting to renal failure requiring dialysis.(5) The use of contrast during TEVAR deployment
may temporarily worsen renal function, practitioners should use low doses of low or iso-osmolar
contrast agents when possible. N-acetylcysteine, sodium bicarbonate infusions, or saline hydration
been utilized to prevent contrast induced nephropathy (CIN). Several small trials have examined the use
of diuretics for CIN prophylaxis, but the results are conflicting.(6,7) Hydration should be judicious since
fluid overload may be pooly tolerated in this patient population may be challenging particularly in the
case of significant ventricular dysfunction.
Vascular complications following TEVAR can include thromboembolism to the mesenteric circulation or
extremities . Monitoring in the immediate postoperative period should include extremity pulse checks
and examination of the patient for signs or symptoms of ischemia. Mesenteric ischemia may present as
vague abdominal pain out of proportion to exam. Furthermore, vascular complications may include
access site bleeding leading to retroperitoneal hemorrhage. The cannula used for TEVAR are large and
may cause vessel injury, although the absolute risk of this complication is considered rare. Patients with
difficult arterial anatomy may require a retroperitoneal approach which is associated with a higher
incidence of retroperitoneal hematoma.(8) The extraperitoneal space may conceal a large hematoma,
which may delay diagnosis. A high index of suspicion should be maintained in patients with unstable
hemodynamics, new abdominal distension and tenderness, or acute anemia requiring transfusion.
Other signs which are more subtle include oliguria or increased hepatic enymes. Diagnosis may be
confirmed by CT scan, ultrasound, or rarely transesophageal echocardiography. Treatment of
retroperitoneal hematoma includes correction of coagulopathy, monitoring for signs of abdominal
compartment syndrome, and supportive therapy. Surgical intervention may be necessary in select
patients to decompress the hematoma.
In summary, the risk of adverse events following TEVAR remains high. An understanding of the
procedure, close monitoring, and rapid diagnosis and treatment of complications can improve
outcomes.
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