Perioperative management - Endovascular Therapy of a Penetrating Atheromatous Aortic Ulcer of the Descending Aorta (PAU, TEVAR)

In the article, the endoluminal exclusion of a penetrating atheromatous ulcer (PAU, eccentric 32 x 24 mm) of the descending aorta is demonstrated. Due to two previous vascular surgical operations in the left groin and severe arteriosclerosis, an extraperitoneal exposure of the external iliac artery is performed.

For a diameter or depth of the ulcer of ≥ 20 mm, elective endovascular treatment is indicated. In cases of signs of impending rupture (pain, extra-aortic blood), endovascular treatment is urgent. Pain is mentioned as one of the main criteria for urgent surgical intervention.

• none except ASA IV

Thorough vascular surgical examination:

• Pulse status
• Doppler legs
• if necessary, walking distance test with concurrent PAD  and poorly palpable foot pulses
• Abdominal ultrasound
• Color duplex carotids
• Echocardiogram
• Stress ECG
• Laboratory investigations (electrolytes, coagulation, renal values, blood count, blood lipids, blood group)
• Chest X-ray
• Spiral CT thorax-abdomen

• Determine blood type, if necessary provide blood products
• Depilate surgical area
• if necessary insert bladder catheter
• prophylactic antibiotic therapy is usually performed and is recommended by the German Society for Vascular Surgery (single-shot Cefuroxime 30 minutes before skin incision), however, the benefit is currently being discussed due to the resistance issues (RKI). 

General Surgical Risks

• Allergy/Intolerance e.g. to latex, medications; circulatory shock, intensive care measures; very rarely severe, possibly permanent damage (organ failure, brain damage, paralysis)
• Wound Infections: medication or surgical measures; sepsis
• Thromboembolisms of the leg and pelvic veins, pulmonary embolism; preventive heparinization → HIT II
• Skin, Tissue, and Nerve Damage due to positioning and procedure-related measures
• Keloids

Specific Procedure Risks

• Temporary Fever
• Vascular Injuries due to advancement of catheters, stent prosthesis; surgical hemostasis, blood transfusions, immediate transition to open surgery; donor blood → hepatitis, HIV
• Post-Bleeding, Hematomas; possibly surgical measures
• Injury to Skin Nerves; sensory disturbances, possibly permanent
• Leg Edema due to damage to lymphatic vessels in the groin; compression stockings, in case of chronic lymphedema medication or physical measures (lymphatic drainage)
• Aneurysm at puncture sites of the arteries or vascular fistula to the adjacent vein; seroma formation
• Infections of the Stent Prosthesis: within days, months, also after years → endocarditis, sepsis; surgical removal of the infected prosthesis
• Injury to Adjacent Organs due to fixation of the aortic prosthesis (esophagus, intestine, lung) → surgical measures, possibly removal of the prosthesis
• Misplacement of the Aortic Prosthesis → possibly open surgical correction
• Leakage of the Aortic Prosthesis → correction by clipping, extension of the existing prosthesis, possibly also open correction
• Side Effects from Iodine-Containing X-Ray Contrast Media → temporary kidney function impairments, rarely permanent damage (dialysis), possibly hyperthyroidism
• Potency Disorders in Men: rarely erectile dysfunction, possibly permanent

Risks from Insufficient Blood Flow

• Extremities: due to occlusion of the stent prostheses and adjacent vascular segments by thrombi, perfusion disturbances of the limbs; renewed surgical intervention, possibly amputation
• Kidneys: restrictions in kidney function due to thromboembolisms → surgical correction, temporary or also permanent dialysis
• Intestine: due to thromboembolisms or misplacement of the vascular prosthesis; surgical measures, intestinal resection, possibly (permanent) artificial anus
• Spinal Cord: temporary sensory disturbances and paralysis of the legs, possibly permanent paraplegia
• Stroke: due to thromboembolisms → paralysis, hearing, speech or vision disturbances, possibly loss of speech, deafness, blindness
• Liver: functional impairment with "jaundice", especially in pre-existing liver disease