Comparative analysis of perioperative outcomes in endovascular abdominal aortic aneurysm repair: Fascia iliaca block versus general anesthesia,a retrospective study

Abstract

Objective

This retrospective study aimed to compare rates of perioperative mortality and morbidity, especially pulmonary complication, between endovascular aneurysm repair (EVAR) performed under general anesthesia (GA) and under fascia iliaca block (FIB).

Methods

Patients diagnosed with infrarenal abdominal aortic aneurysm (AAA) who were treated with EVAR were included. Retrospective review of electronic medical records was performed. Patient characteristics, operative details, and postoperative results including mortality and morbidity within 30 days were collected. Statistical analysis to compare postoperative outcomes between EVAR under FIB and EVAR under GA was performed. A univariate analysis was conducted to identify factors associated with increased 30-day mortality.

Results

This study included 119 patients, 75 in the FIB group and 44 in the GA group. Most patients were male, with 62 (82.5%) in the FIB group and 31 (70.2%) in the GA group, and most patients were hypertensive, with 57 (76%) in the FIB group and 36 (81.8%) in the GA group. Smoking and coronary artery disease (CAD) was more prevalent in the FIB group, p < .05. Thirty-day mortality was not significantly different between the FIB group and the GA group (1 (1.3%) vs 2 (4.5%), p = .554). Pulmonary complication was lower in the FIB group than in the GA group (1.3% vs 11.4%, p = .026). ICU stay was shorter in the FIB group than in the GA group (0.2 vs 4.5 days, p = .012). Univariate analysis showed that chronic obstructive pulmonary disease (COPD) was associated with higher 30-day mortality.

Conclusions

Endovascular aneurysm repair under FIB was feasible. Compared to GA, this approach resulted in lower postoperative pulmonary complications and shorter ICU stay.

Keywords

Abdominal aortic aneurysm general anesthesia fascia iliaca block endovascular aneurysm repair locoregional anesthesia

Background

Endovascular aneurysm repair (EVAR) is a current standard treatment of infrarenal abdominal aortic aneurysm (AAA), especially for patients with a moderate life expectancy.¹ However, open aortic aneurysm repair performing under GA may be considered for low surgical risk patients. For EVAR, there are a variety of anesthetic solutions including GA, spinal anesthesia, and local anesthesia with or without sedation depending on the patient physical status, complexity of the anatomy, and surgeon experience. In a meta-analysis study comparing open aneurysm repair and EVAR, the results showed lower postoperative mortality in EVAR.² However, GA has been reported to increase pulmonary complications after EVAR compared with spinal and local anesthesia.³ Subgroup analysis from a randomized control trial of ruptured AAA indicated that EVAR under local anesthesia improved survival.⁴ The influence of the mode of anesthesia on postoperative outcomes is not well studied in elective settings.¹ Conversely, in some patients, local anesthesia may not effectively prevent discomfort during device insertion caused by irritation of fascia and manipulation of the periarterial nerve supply. Alternatively, results obtained in the cases of transfemoral thromboembolectomy indicated that a fascia iliaca block (FIB) could be successfully applied in patients with acute limb ischemia.⁵ Based on these results, our institution applies the FIB in EVAR and achieved satisfactory outcomes. In this study, we assessed perioperative mortality and morbidity in patients who underwent EVAR either under general anesthesia (GA) or FIB and herein provide the first report on the use of FIB in EVAR. We have the hypothesis that FIB might decrease postoperative mortality, morbidity, and length of ICU stay.

Methods

Data collection

This is a retrospective cohort study that was approved by Maharat Nakhon Ratchasima Hospital Institutional Review Board (approval number 009/2023). Medical records of all patients aged 18 and over who underwent EVAR in our institution from January 2019 to December 2021 were reviewed. Patients who underwent EVAR as a primary operation for treatment of infrarenal AAA were included. Patients who underwent complex EVAR were excluded because GA was the best choice. Patients’ demographic data, operative details, and perioperative outcomes were collected. Pulmonary complications included pneumonia, reintubation, and prolonged intubation with and without tracheostomy. Cardiac complications included arrhythmia, congestive heart failure, and myocardial infarction. Renal complications included rising serum creatinine by 0.3 mg/dL or more within 48 h, rising serum creatinine to 1.5 times or more than baseline of the prior 7 days, and temporary or long-term hemodialysis.

Anesthetic method

In our institution, GA was performed by anesthesiologists and FIB by vascular surgeons under ultrasound guidance, using an infrainguinal approach.⁶ All patients in the GA group were inducted with a combination of propofol, cisatracurium, and fentanyl prior to intubation. Anesthesia was maintained using either sevoflurane or desflurane along with cisatracurium for muscle relaxation throughout the procedure. For the FIB group, we performed FIB by a single injection technique, a 30 cc-diluted lidocaine with epinephrine was injected beneath the fascia iliaca of both sides, and the maximum dose of lidocaine was 7 mg/kg.⁷ For example, in a patient with 60 kg body weight, the maximum dose was 42 cc of 1% lidocaine with epinephrine. We prefer to use 20 cc of lidocaine diluted with 10 cc of normal saline solution for FIB each side (30 cc-diluted lidocaine). In this group, most EVAR procedures were performed under FIB alone. For the patients who had a history of spinal disease, they often had a back pain after 1–2 h, and administration of fentanyl was necessary. In the last sub-group of the patients who were not able to co-operate after the beginning of EVAR procedure, administration of fentanyl and dexmedetomidine was performed. The details of FIB procedure are described in Figure 1. We performed EVAR under GA from January 2019 to March 2020 and initiated to perform EVAR under FIB from April 2020 to December 2021. The mode of anesthesia was chosen after the discussion between vascular surgeon and anesthesiologist. We considered FIB first if estimated operative time is less than 4 h. The exclusion criteria for FIB were the patients unlikely to be able to co-operate with awake operation, previous groin surgery, previous groin radiation, patients who were on anticoagulants, and a history of bleeding disorder disease. Before performing FIB, all patients were informed about the details of the procedure and signed the informed consent. All vascular surgeons who performed FIB had the experience of at least five successful procedures of FIB.

Figure 1.

(A) Ultrasound probe was placed in the transverse position at common femoral artery bifurcation level, and the 21-G needle was advanced around the femoral nerve. (B) The femoral nerve (black arrow) was clearly identified after lidocaine (white small arrow) was injected through the 21-G needle (white large arrow). (C) The ultrasound probe was changed to longitudinal position. (D) The 21-G needle (large white arrow) was advanced beneath the fascia iliaca (small white arrow), lidocaine (large black arrow, 30 cc) was injected, and the femoral nerve was clearly identified.

Statistical analysis

All data analyses were performed using a statistical software package (SPSS 26, IBM Corporation). Continuous variables were presented as mean and SD or range and IQR where appropriate. Categorical variables were presented as a percentage. Independent t test or Chi-square test was used to calculate significant differences in continuous and categorical variables, respectively. A univariate analysis was conducted to identify any factors associated with 30-day mortality. p-Values less than .05 were considered as statistically significant.

Results

Endovascular aneurysm repair was performed in 168 patients during the study period from January 2019 to December 2021. Forty-nine patients who presented with ruptured AAA, juxtarenal AAA, pararenal AAA, and thoracoabdominal aortic aneurysm (TAAA) were excluded from the study. A total of 119 patients were included in this study. A total of 44 patients underwent EVAR under GA and 75 patients underwent FIB. In the FIB group, 40 (53%) patients underwent EVAR under FIB alone, 20 (27%) patients under FIB and administration of fentanyl, and 15 (20%) patients under IFB and administration of fentanyl and dexmedetomidine. The study flow diagram of each group is described in Figure 2.

Figure 2.

Flow diagram showed the number of the patients who underwent EVAR during the study period, 119 patients included in the study, 44 patients in the GA group, and 75 patients in the FIB group.

Demographic and clinical characteristics of patients

Most patients were male, 62 (82.5%) in the FIB group and 31 (70.5%) in the GA group. The mean patient age was 73.7 years in the FIB group and 74.3 years in the GA group. The major comorbidity was hypertension, present in 57 (76%) patients in the FIB group and 36 (81.8%) patients in the GA group. Baseline characteristics were similar between both groups; however, the prevalence of smoking and coronary artery disease (CAD) was higher in the FIB group, p < .05. Demographic and clinical characteristics of patients who underwent EVAR under FIB and EVAR under GA are summarized in Table 1.

Table 1.

Demographic and clinical characteristics of patients who underwent EVAR under FIB and EVAR under GA.

	EVAR under FIB (n = 75)	EVAR under GA (n = 44)	p-Value
Male, n (%)	62 (82.5)	31 (70.5)	.120
Age, year ± SD	73.7 ± 8.0	74.3 ± 10.2	.727
Smoking, n (%)	18 (24.0)	4 (9.1)	.043
Underlying comorbidities
Diabetes mellitus, n (%)	15 (20.0)	10 (22.7)	.724
Hypertension, n (%)	57 (76.0)	36 (81.8)	.458
COPD, n (%)	7 (9.3)	5 (11.4)	.475
CAD, n (%)	9 (12.0)	0 (0)	.013
Chronic kidney disease, n (%)	19 (25.3)	7 (15.9)	.230
Stroke, n (%)	11 (14.7)	8(18.2)	.603
Aortic neck angulation >75°	12 (16.0)	8 (18.2)	.759
ASA classification
ASA 1	0 (0)	0 (0)	.657
ASA 2	3 (4.0)	1 (2.3)
ASA 3	68 (90.7)	39 (88.6)
ASA 4	4 (5.3)	4 (9.1)

Values are mean ± SD or n (%).

Statistical significance = p < .05.

COPD, chronic obstructive pulmonary disease; CAD, coronary artery disease.

Operative details

Endovascular aneurysm repair under FIB was successfully performed in all patients, and no conversion from FIB to GA was seen. Duration of anesthesia was around 5–6 h. Fluoroscopic time was shorter in the FIB group (23.5 ± 11.6 min vs 36.9 ± 25.2 min, p = .008). Contrast usage was lower in the FIB group (61.4 ± 26.1 mL vs 84.1 ± 45.6 mL, p = .034). Moreover, blood loss was lower in the FIB group than in the GA group (125.2 ± 126.4 mL vs 237.3 ± 238 mL, p = .005).

Postoperative results

The overall 30-day mortality rate was 2.52%. When compared between groups, the mortality rate was not significant between both the groups, with 1 (1.3%) patient death in the FIB group versus 2 (4.5%) patients’ death in the GA group, p = .554. The cause of death was pulmonary complications (2 in the GA group) and necrotizing fasciitis (1 in the FIB group). Patients in the FIB group had lower rates of pulmonary complications, with 1 (1.3%) FIB patient experiencing pulmonary complications versus 5 (11.4%) patients in the GA group (p = .026). ICU stay was shorter in the FIB group than in the GA group (0.2 ± 0.7 days vs 4.5 ± 10.8 days, p = .012). Operative details and postoperative results are summarized in Table 2.

Table 2.

Operative details and postoperative results of patients who underwent EVAR under FB and EVAR under GA.

	EVAR under FIB (n = 75)	EVAR under GA (n = 44)	p-Value
30-Day mortality, n (%)	1 (1.3)	2 (4.5)	.554
Pulmonary complication, n (%)	1 (1.3)	5 (11.4)	.026
Cardiac complication, n (%)	1 (1.3)	3 (6.8)	.142
Renal complication, n (%)	3 (4.0)	6 (13.6)	.075
Access site complication, n (%)	0 (0)	0 (0)
ICU stay, days ± SD	0.2 ± 0.7	4.5 ± 10.8	.012
Readmission in 30 days, n (%)	2 (2.7)	0 (0)	.530
Fluoroscopic time, min ± SD	23.5 ± 11.6	36.9 ± 25.2	.008
Contrast usage, ml ± SD	64.1 ± 26.1	84.1 ± 45.6	.034
Blood loss, ml ± SD	125.2 ± 126.4	237.3 ± 238.0	.005

Values are mean ± SD or n (%).

Statistical significance = p < .05.

Factors associated with 30-day mortality

Results of the univariate analysis (Table 3) indicated that COPD was associated with a greater risk of 30-day mortality, odds ratio 4.45, and p = .009. However, when evaluated using multivariable analysis, we could not find any association with this factor.

Table 3.

Univariate analysis of factors associated with 30-day mortality.

Factors	Patients survived in 30 days (n = 116)	Patients died in 30 days (n = 3)	OR	p-Value
GA, n (%)	42 (36.2)	2 (66.7)	1.113	.281
Male, n (%)	90 (77.6)	3 (100)	1.501	.354
Age, year ± SD	73.8 ± 8.8	80.3 ± 5.9		.204
Smoking, n (%)	22 (19.0)	0 (0)	1.244	.403
Underlying comorbidities
Diabetes mellitus, n (%)	24 (20.7)	1 (33.3)	0.252	.596
Hypertension, n (%)	90 (77.6)	3 (100)	1.501	.354
COPD, n (%)	15 (12.9)	2 (66.7)	4.452	.027
CAD, n (%)	16 (13.8)	0 (0)	0.878	.616
Chronic kidney disease, n (%)	24 (20.7)	2 (66.7)	2.851	.057
Stroke, n (%)	19 (16.4)	0 (0)	1.058	.591
Aortic neck angulation >75°	20 (17.2)	0 (0)	1.120	.430
ASA classification
ASA 1	0 (0)	0 (0)		.841
ASA 2	4 (3.4)	0 (0)
ASA 3	104 (89.7)	3 (100)
ASA 4	8 (6.9)	0 (0)
Operative time, min	117.4 ± 69.9	185.0 ± 129.9		.108
Contrast used, ml	74.4 ± 38.4	55.0 ± 10.2		.618
Fluoroscopic time, min	30.2 ± 20.8	31.0 ± 9.8		.969
Blood loss, ml	167.1 ± 175.9	300.0 ± 282.8		.296

Values are mean ± SD or n (%).

Statistical significance = p < .05.

COPD, chronic obstructive pulmonary disease; CAD, coronary artery disease.

Discussion

Local anesthesia is the preferred choice for patients undergoing EVAR for ruptured AAA to reduce risk of postoperative mortality.^8–10 But for the elective EVAR procedure, there is no clear evidence to support a survival benefit of any anesthetic method.¹¹ Evidence suggests that GA is associated with potential complications such as hypotension, arrhythmia, postoperative respiratory failure, and delirium.^12,13 Post-induction hypotension usually occurs during the first 20 minutes after anesthesia induction.¹⁴However, if the hypotensive episodes last longer, they are associated with further increased perioperative morbidity rates.¹⁵A study compared carotid endarterectomy under GA and regional anesthesia resulting in lower cardiopulmonary complications in the regional anesthesia group.¹⁶ In another study that compared regional anesthesia and GA in surgical patients with chronic obstructive pulmonary disease, the results showed significantly lower incidences of pneumonia, prolonged ventilator dependence, and unplanned postoperative intubation in the regional group.¹⁷ Moreover, the deeper anesthetic level of GA is associated with a higher risk of postoperative delirium and 1-year cognitive impairment.^13,18 Awareness that occurred in patients who undergone surgery under GA is a significant source of anxiety and results in post-traumatic stress disorder.¹⁹

A study comparing EVAR under GA with regional or local anesthesia showed that GA results in higher pulmonary morbidity and longer lengths of hospital and ICU stay.^3,20We proposed a new strategy to perform EVAR under FIB, and we found significantly lower postoperative pulmonary complications that were the major cause of death in this study. Although the 30-day mortality was not significantly different between both the groups, the trend is lower in the FIB group. The univariate analysis in our study indicates that only COPD was associated with a greater risk of 30-day mortality. Some studies demonstrate ASA physical status was associated with increased postoperative mortality^21–23; however, this finding did not present in this study. Operative time, contrast use, and blood loss were not associated with postoperative mortality.

Fascia iliaca block was also preferred to perform in other operations. There is evidence suggesting that FIB resulted in better hemodynamic parameters during lower-limb surgery for acute ischemia compared to spinal anesthesia.⁴ Fascia iliaca block also resulted in the reduced need for systemic analgesics and opioids and led to lower rates of complications in patients with neck of femur fracture.²⁴ A study of transfemoral transcatheter aortic valve replacement (TAVR) under FIB compared to GA found that TAVR under FIB was associated with shorter procedure time, and shorter hospital and ICU stay. Transcatheter aortic valve replacement under FIB also resulted in better 1-year quality of life.²⁵

There were several limitations observed in this study. Firstly, a less fluoroscopic time, contrast use, and blood loss in the FIB group may be influenced by operator experience that increases during the latter period of this study. Secondly, its retrospective nature may have introduced selection bias, as evidenced by higher proportion of active smokers and CAD in the FIB group.²⁶ To mitigate this issue, future investigations employing appropriate randomization techniques are warranted. Thirdly, the sample size, particularly in the GA group, may have been insufficient. According to Papavasiliou et al., a study aimed at demonstrating differences in postoperative morbidity would require an estimated sample size of 68 per group, with a 5% alpha error and a 20% beta error. This limitation could potentially explain the lack of significant association between COPD and pulmonary complications in multivariate analysis, despite its significance in univariate analysis. Consequently, further prospective trials with adequate sample sizes are necessary to verify the benefits of regional anesthesia.^27,28

Conclusions

Endovascular aneurysm repair under FIB was safe and feasible. Compared to GA, FIB for EVAR resulted in lower postoperative pulmonary complications, shorter ICU stay, and more reasonable resource utilization.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Veera Suwanruangsri

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