Case report
Transcaval approach for aortic endoprosthesis insertion. A new anesthetic challenge
Abordaje transcava para inserción de endoprótesis aórtica. Un nuevo reto anestésico
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A new anesthetic challenge" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "623" "paginaFinal" => "626" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Alegre Cortés, A. Bilbao Ares, A. Pola Jiménez, Y. Abaurrea Díaz, S. Fernández Alonso, M. Salvador Bravo" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Alegre Cortés" "email" => array:1 [ 0 => "andres.alegre.cortes@navarra.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Bilbao Ares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Pola Jiménez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Y." "apellidos" => "Abaurrea Díaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "S." "apellidos" => "Fernández Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Salvador Bravo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio Anestesia y Reanimación, Hospital Universitario de Navarra, Pamplona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio Cirugía Vascular y Angiología, Hospital Universitario de Navarra, Pamplona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Abordaje transcava para inserción de endoprótesis aórtica. Un nuevo reto anestésico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 584 "Ancho" => 755 "Tamanyo" => 44604 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Aorta arteriography showing aortic ulcer (arrow). (B) Pre-operative 3D digital subtraction angiography.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Endovascular stenting to treat aortic pathologies is increasingly chosen over traditional surgical repair in routine clinical practice.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, there are a number of cases in which the endovascular approach must be ruled out for various reasons. A new approach to the abdominal aorta through the inferior vena cava has recently been described for patients in whom other vascular approaches are infeasible and the transthoracic approach is totally or partially contraindicated.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">All anaesthesiologists must have a working knowledge of aortic syndrome management, despite its complexity. The introduction of new surgical approaches supported by little or no scientific evidence and possibly associated with complications is a challenge for the anaesthesiologist. We present the first case in Spain of aortic stent placement through the inferior vena cava.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 55-year-old man with a history of atrial fibrillation (AF), arterial hypertension, ischaemic heart disease, functional class II heart failure, morbid obesity (body mass index of 43) and peripheral vascular disease under follow-up for aortoiliac thrombosis and admitted to hospital for pneumococcal aortitis at multiple sites together with a large penetrating thoracic aortic ulcer (35 × 28 mm) and another smaller infrarenal ulcer (24 × 33 mm) with perivascular inflammatory changes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The femoral approach was ruled due to the aforementioned aortoiliac thrombosis. An upper extremity approach was not feasible either, since an 18 F aortic stent at least would be required, which is too large for the subclavian approach. Open surgery needed to be avoided due to the patient’s comorbid burden and high surgical risk. After weighing up the risk-benefit, therefore, it was decided to access the inferior vena cava through the right femoral vein and then puncture the vena cava to access the abdominal aorta and release the aortic stent. To our knowledge, this is the first case of aortic pathology management using this approach performed and reported in Spain.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The most critical steps in this procedure were puncture of the inferior vena cava and the aorta to insert the metal guidewire, and closure of the opening in the aortic wall using an automatic occluder.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The potential complications specific to this procedure are massive intra-abdominal bleeding (due to uncontained rupture of the inferior vena cava or abdominal aorta), right heart strain (due to the persistence of a symptomatic aortocaval fistula) and, exceptionally, the pulmonary embolism. (PE) due to manipulation of the vena cava or migration of the occluder.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The other critical steps and potential complications are the same as those encountered in any other aortic endovascular procedure performed through conventional vascular access.</p><p id="par0035" class="elsevierStylePara elsevierViewall">After discussing the uniqueness of the case with the surgeons, we devised an anaesthesia strategy that would allow the team to treat the aforementioned complications by placing large calibre venous catheters, ensuring the immediate availability of blood products, and performing invasive haemodynamic monitoring (through pulse contour analysis) to obtain advance warning of impending complications.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient entered the operating room with good respiratory mechanics, and known AF with ventricular response of 60 beats per minute. Induction and intubation were uneventful. Anaesthesia was maintained with sevoflurane and neuromuscular relaxation was maintained with rocuronium boluses guided by neuromuscular monitoring. The patient remained stable with no need for haemodynamic support and no respiratory complications. As right-sided vascular accesses would be required during surgery, a catheter was inserted into the left radial artery for invasive blood pressure monitoring and a large-calibre venous catheter was inserted in the left internal jugular vein (double lumen, 9 F) with which we also monitored central venous pressure. Both vascular lines were placed uneventfully under ultrasound guidance. Anaesthesia depth and bifrontal regional oxygen saturation were also monitored. Systemic heparinization was monitored by measuring activated clotting time and was completely reversed with protamine at the end of surgery. To enter the aorta from the inferior vena cava, a guide wire connected to an electrosurgery pencil was used to puncture the wall at a point of close contact between the vena cava and artery that had previously been chosen after reviewing the CAT images (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The procedure was performed without any complications (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C) and the patient remained stable throughout. He was extubated in the operating room with no signs of neurological deficit. He remained in the post-anaesthesia care unit for 24 h, and was then transferred to the ward, from where he was discharged home without any complications. Informed consent was obtained from the patient to publish this case report.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Anaesthesia management during procedures that involve the aorta is always a challenge due to the complexity of the technique and the high comorbid burden. Nevertheless, these procedures are becoming increasingly common, and surgical teams are becoming adept at avoiding the associated complications. Invasive monitoring is highly recommended, and can be more or less extensive depending on the patient's comorbidity and the surgical technique. The choice of anaesthesia technique will depend on the aforementioned factors and the experience of the anaesthesiologist, and the procedure can be performed under general, locoregional, or even local anaesthesia with various levels of sedation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Some of the most common comorbidities encountered in these patients are thrombosis and arterial and vascular occlusion, the latter being the most commonly described reason for ruling out endovascular access. Several large series have reported that in 12%–19% of candidates for transaortic valve replacement the femoral vein is unsuitable for the procedure,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> leaving clinicians with the challenge of finding new access routes to the aorta. Transthoracic access (transapical or transaortic) is associated with worse outcomes, more vascular complications, and higher mortality compared to the traditional arterial route<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Greenbaum recently described an approach to the abdominal aorta from the femoral venous system through the inferior vena cava, a technique indicated in cases where access from other peripheral arteries is impossible and the transthoracic approach is absolutely or relatively contraindicated.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The introduction of new surgical approaches brings with it new complications, and the most dreaded complication of the procedure described here is uncontrollable intra-abdominal bleeding. A comprehensive review of transaortic valve implantation showed a 13% rate of major vascular complications, with 1%–2% of patients developing retroperitoneal haematoma.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Bleeding complications are relatively rare, because the pressure in an intact retroperitoneum exceeds the pressure in the vein, thus preventing bleeding from the puncture in the vena cava. The opening in the wall of the aorta must be closed with an automatic occluder to prevent both bleeding and the persistence of an aortocaval fistula.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In our case, we chose the widely used Amplatzer occluder (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The orifice is not closed immediately, and a small tolerable aortocaval fistula remains that closes minutes to days later. This small fistula is only likely to cause symptoms from the start in patients with severe pulmonary hypertension or severe right ventricular dysfunction. However, persistent fistulas are almost entirely self-limiting in the first 12 months, and there is no mention in the literature of any association between these and high-output heart failure due to left-right shunt, or between aortocaval fistulas and other vascular complications.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Other acute complications mentioned in the case report involve the migration of emboli or even of the occluding device to the pulmonary circulation. Endovascular aortic repair is known to be associated with PE in the early postoperative period; however, it rarely manifests during surgery.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Although some cases of PE due to mechanical causes (migration of the occluder) have been described in the literature, they usually occur in patients undergoing closure of atrial septal defects.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Given our patient's comorbidity and the surgical team’s lack of experience with this procedure, we decided to perform general anaesthesia with essential invasive (invasive blood pressure, central venous pressure) and non-invasive monitoring. This provided us with real time information on the patient’s status, particularly during the aforementioned critical steps. If the patient had presented massive intra-abdominal bleeding, we planned to activate a massive transfusion protocol while the bleeding was controlled surgically. Another possible complication would have been poorly tolerated right overload secondary to the creation of the aortocaval fistula. Although this was unlikely because our patient did not have a history of pulmonary hypertension, had it occurred we planned to reduce preload under strict monitoring and administer inotropic support.</p><p id="par0070" class="elsevierStylePara elsevierViewall">These new surgical approaches are challenging due to the scant evidence in the literature. The authors of studies defining the technique describe the use of general anaesthesia and “moderate sedation.” According to one author, general anaesthesia is not required for the procedure, but awake patients will required additional sedation prior to performing the transcaval fistula.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> A multicentre study involving several European hospitals performing this new approach for transcatheter aortic valve implantation reported that most cases were performed under general anaesthesia and the rest under conscious sedation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The case reports published so far have not explained in any detail the anaesthesia technique used with the transcaval approach,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In fact, none of the descriptions of this technique have discussed any anaesthesia-related considerations, no doubt due to the novelty of the approach. The transcaval approach as an alternative to vascular access in aortic repair procedures has proven to be both effective and safe. Given the growing prevalence of aortic syndrome in the general population, there is no doubt that this procedure will be performed more often. This is the first published case report in Spain of the new transcaval approach to aortic stent implantation. We believe it is important to share this first experience and in this way extend the use of this procedure in Spain.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical considerations</span><p id="par0075" class="elsevierStylePara elsevierViewall">Informed consent was obtained from the patient to publish case report and the associated images.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0080" class="elsevierStylePara elsevierViewall">There was no funding for the publication of this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2260311" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1885940" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2260312" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1885941" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical considerations" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-05-20" "fechaAceptado" => "2023-09-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1885940" "palabras" => array:4 [ 0 => "Aortic syndrome" 1 => "Aortic endoprosthesis" 2 => "Transcaval access" 3 => "Endovascular Surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1885941" "palabras" => array:4 [ 0 => "Síndrome aórtico" 1 => "Endoprótesis aórtica" 2 => "Abordaje transcava" 3 => "Cirugía endovascular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The treatment of acute aortic syndrome has been benefited in recent years from the huge progress in endovascular techniques, compared to classical surgical treatment, by open surgery. Nevertheless, for endovascular treatment to be successful, it is essential for the patient to present adequate vascular access. Those cases with unfavourable vascular anatomy make it necessary to consider open surgery with significant morbidity, or even to reject surgery. A new approach to the abdominal aorta has recently been described as an indication for these patients with impossibility of other vascular access and absolute or relative contraindication to the transthoracic approach.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The anesthetic management of the aortic syndrome is well known and, even though there are a variety of options, all of them have proven safety and efficacy. The implementation of new surgical approaches and new possible complications imply a challenge for the anesthesiologist which, for now, has little or none scientific evidence.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We present the first case of transcaval aortic endoprosthesis implantation in Spain, its anesthetic implications, and a review of the literature.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El tratamiento del síndrome aórtico agudo en los últimos años se ha beneficiado del enorme avance en las técnicas endovasculares, frente al tratamiento quirúrgico clásico, mediante cirugía abierta. Sin embargo, para que el tratamiento endovascular tenga éxito, es imprescindible que el paciente presente unos accesos vasculares adecuados. Aquellos casos con una anatomía vascular desfavorable obligan a plantear una cirugía abierta con importante morbilidad, o incluso a desestimar la cirugía. Recientemente se ha descrito un nuevo abordaje a la aorta abdominal a través de la vena cava inferior como indicación para estos pacientes con imposibilidad de otros accesos vasculares y contraindicación absoluta o relativa del abordaje transtorácico.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El manejo anestésico del síndrome aórtico es bien conocido y, si bien existe variedad de opciones, todas ellas son de seguridad y eficacia probadas. La implantación de nuevos abordajes quirúrgicos y nuevas posibles complicaciones implican un reto para el anestesiólogo que, por el momento, dispone de poca o ninguna evidencia científica.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Presentamos el primer caso realizado en España de implantación de endoprótesis aórtica mediante abordaje transcava, sus implicaciones anestésicas y una revisión de la bibliografía.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 584 "Ancho" => 755 "Tamanyo" => 44604 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Aorta arteriography showing aortic ulcer (arrow). (B) Pre-operative 3D digital subtraction angiography.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 916 "Ancho" => 930 "Tamanyo" => 103090 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Steerable introducer in vena cava resting on the aortic wall to perform puncture. (B) Closure of the aorto-cava fistula with the Amplatzer occluder. 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