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

• ITN

Supine position, both arms abducted (if necessary, right arm adducted)

The surgeon stands on the right, with the assistant opposite. Next to the surgeon, towards the foot end, stands the instrumenting OR specialist.

• small vessel sieve
• sufficient guidewires (Terumo®, Lunderquist®, Amplatz®)
• guide catheter
• dilation balloons in various sizes
• DSA system, contrast medium high-pressure pump
• suitable endoluminal vascular prosthesis according to preoperative measurement
• for emergencies, keep instrumentation for open conversion ready

Postoperative Analgesia

Follow the link here to PROSPECT (Procedure Specific Postoperative Pain Management) and to the current guideline Treatment of acute perioperative and posttraumatic pain.

Medical Follow-up Care

• 24-hour follow-up care in intensive care unit, if necessary intermediate care
• Normal ward possible from the 1st postoperative day
• close monitoring of heart-circulation-lungs
• coagulation monitoring (e.g., consumption coagulopathy)

Mobilization

• from the 1st postoperative day

Physiotherapy

• not necessary

Diet Build-up

• 4-6 hours postoperatively

Stool Regulation

• generally not necessary

Incapacity for Work

• approx. 3 weeks