Type of Anesthesia for Endovascular Abdominal Aortic Aneurysm Repair

Published:October 17, 2018DOI:https://doi.org/10.1053/j.jvca.2018.09.018


      Endovascular aneurysm repair (EVAR) is used increasingly in the management of patients with abdominal aortic aneurysms (AAAs), including in the emergency setting for ruptured AAA. The lower mortality among patients undergoing emergency EVAR under local anesthesia (LA) observed in the Immediate Management of Patients with Rupture: Open Versus Endovascular Repair trial has sparked renewed interest in the anesthesia choice for EVAR. This systematic review evaluates the effect of mode of anesthesia on outcomes after EVAR.


      The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The primary outcome was in-hospital/30-day mortality, and both emergency and elective EVAR were included. The relative risk of death was estimated for each individual study without adjustment for potential confounding factors.




      A total of 39,744 patients from 22 nonrandomized studies were included in the analysis.



      Measurements and Main Results

      Sixteen studies in 23,202 patients compared LA to general anesthesia (GA) and reported in-hospital/30-day mortality. The unadjusted risk of death after emergency EVAR with LA was lower than with GA. Trends in elective surgery were less clear.


      There is some evidence across both emergency and elective settings to suggest that mode of anesthesia may be associated with improved outcomes. In particular, LA appears to have a positive effect on outcome after emergency EVAR. Because of the lack of randomized trial data, a significant risk of confounding remains. The optimal mode of anesthesia for EVAR should be investigated further and the reasons why particular anesthesia techniques are chosen for particular patients identified.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Holt PJE
        • Poloniecki JD
        • Gerrard D
        • et al.
        Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery.
        Br J Surg. 2007; 94: 395-403
        • Karthikesalingam A
        • Holt PJ
        • Vidal-Diez A
        • et al.
        Mortality from ruptured abdominal aortic aneurysms: Clinical lessons from a comparison of outcomes in England and the USA.
        Lancet. 2014; 383: 963-969
      1. Vascular Society of Great Britain and Ireland. Vascular Services Quality Improvement Programme. Survival rates for patients undergoing abdominal aortic surgery, annual report 2017. Available at: https://www.vsqip.org.uk/reports/2017-annual-report/. Accessed 5 January 2018.

        • Elkouri S
        • Gloviczki P
        • McKusick MA
        • et al.
        Perioperative complications and early outcome after endovascular and open surgical repair of abdominal aortic aneurysms.
        J Vasc Surg. 2004; 39: 497-505
        • Alcorn HG
        • Wolfson Jr, SK
        • Tyrrell K
        • et al.
        Risk factors for abdominal aortic aneurysms in older adults enrolled in The Cardiovascular Health Study.
        Artherioscler Thromb Vasc Biol. 1996; 16: 963-970
        • Parodi JC
        • Palmaz JC
        • Barone HD
        Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.
        Ann Vasc Surg. 1991; 5: 491-499
        • EVAR Trial participants
        Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): Randomized controlled trial.
        The Lancet. 2005; 365: 2187-2192
        • EVAR Trial participants
        Endovascular aneurysm repair and outcomes in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2) randomized controlled trial.
        The Lancet. 2005; 365: 2179-2186
        • Greenhalgh RM
        • Brown LC
        • et al.
        • The UK EVAR Trial Investigators
        Endovascular versus open repair of abdominal aortic aneurysm.
        N Engl J Med. 2010; 362: 1863-1871
        • Brown LC
        • Thompson SG
        • Greenhalgh RM
        • et al.
        Incidence of cardiovascular events and death after open or endovascular repair of abdominal aortic aneurysm in the randomized EVAR Trial 1.
        Br J Surg. 2011; 98: 935-942
        • Sweeting MJ
        • Balm R
        • Desgranges P
        • et al.
        Individual‐ patient meta‐ analysis of three randomized trials comparing endovascular versus open repair for ruptured abdominal aortic aneurysm.
        Br J Surg. 2015; 102: 1229-1239
        • Aadahl P
        • Lundbom J
        • Hatlinghus S
        • et al.
        Regional anesthesia for endovascular treatment of abdominal aortic aneurysms.
        J Endovasc Surg. 1997; 4: 56-61
        • Henretta JP
        • Hodgson KJ
        • Mattos MA
        • et al.
        Feasibility of endovascular repair of abdominal aortic aneurysms with local anesthesia with intravenous sedation.
        J Vasc Surg. 1999; 29: 793-798
        • Ruppert V
        • Leurs LJ
        • Steckmeier B
        • et al.
        Influence of anesthesia type on outcome after endovascular aortic aneurysm repair: An analysis based on EUROSTAR data.
        J Vasc Surg. 2006; 44: 16-21
        • Ruppert V
        • Leurs LJ
        • Rieger J
        • et al.
        Risk-adapted outcome after endovascular aortic aneurysm repair: Analysis of anesthesia types based on EUROSTAR data.
        J Endovasc Ther. 2007; 14: 12-22
        • Bakker EJ
        • van de Luijtgaarden KM
        • van Lier F
        • et al.
        General anesthesia is associated with adverse cardiac outcome after endovascular aneurysm repair.
        Eur J Vasc Endovasc Surgery. 2012; 44: 121-125
        • Karthikesalingam A
        • Thrumurthy SG
        • Young EL
        • et al.
        Locoregional anesthesia for endovascular aneurysm repair.
        J Vasc Surg. 2012; 56: 510-519
        • Powell JT
        • Hinchliffe RJ
        • Thompson MM
        • et al.
        Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm.
        Br J Surg. 2014; 101: 216-224
      2. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.02 [updated September 2009]. Available at: http://handbook.cochrane.org/v5.02/. Accessed 15 June 2015.

        • Petrie JC
        • Grimshaw JM
        • Bryson A
        The Scottish Intercollegiate Guidelines Network Initiative: Getting validated guidelines into local practice.
        Health Bull (Edinb). 1995; 53: 345-348
        • Keaney M
        • Lorimer AR
        Auditing the implementation of SIGN (Scottish Intercollegiate Guidelines Network) clinical guidelines.
        Int J Health Care Qual Assur Inc Leadersh Health Serv. 1999; 12: 314-317
        • Sen A
        • Basar Erdivanli B
        • Özdemir A
        • et al.
        Efficacy of continuous epidural analgesia versus total intravenous analgesia on postoperative pain control in endovascular abdominal aortic aneurysm repair: A retrospective case-control study.
        BioMed Research International. 2014;
        • Kim M
        • Brady JE
        • Li G
        Anesthetic technique and acute kidney injury in endovascular abdominal aortic aneurysm repair.
        J Cardiothorac Vasc Anesth. 2014; 28: 572-578
        • Geisbusch P
        • Katzen BT
        • Machado R
        • et al.
        Local anesthesia for endovascular repair of infrarenal aortic aneurysms.
        Eur J Vasc Surg. 2011; 42: 467-473
        • Edwards MS
        • Andrews JS
        • Edwards AF
        • et al.
        Results of endovascular aortic aneurysm repair with general, regional and local/monitored anesthesia care in the American College of Surgeons National Surgical Quality improvement Program database.
        J Vasc Surg. 2011; 54: 1273-1282
        • Wax DB
        • Garcia C
        • Campbell N
        • et al.
        Anesthetic experience with endovascular aortic aneurysm repair.
        Vasc Endovasc Surg. 2010; 44: 279-281
        • Falkensammer J
        • Hakaim AG
        • Klocker J
        • et al.
        Paravertebral blockade with propofol sedation versus general anesthesia for elective endovascular abdominal aortic aneurysm repair.
        Vascular. 2006; 14: 17-22
        • Verhoeven EL
        • Cina CS
        • Tielliu IF
        • et al.
        Local anesthesia for endovascular abdominal aortic aneurysm repair.
        J Vasc Surg. 2005; 42: 402-409
        • Parra JR
        • Crabree T
        • McLafferty RB
        • et al.
        Anesthesia technique and outcome of endovascular aneurysm repair.
        Ann Vasc Surg. 2005; 19: 123-129
        • De Virgilio C
        • Romero L
        • Donayre C
        • et al.
        Endovascular abdominal aortic aneurysm repair with general versus local anesthesia: A comparison of cardiopulmonary morbidity and mortality rates.
        J Vasc Surg. 2002; 36: 988-991
        • Bettex DA
        • Lachat M
        • Pfammatter T
        • et al.
        To compare general, epidural and local anesthesia for endovascular aneurysm repair (EVAR).
        Eur J Vasc Endovasc Surg. 2001; 21: 179-184
        • Cao P
        • Zannetti S
        • Parlani G
        • et al.
        Epidural anesthesia reduces length of hospitalization after endoluminal abdominal aortic aneurysm repair.
        J Vasc Surg. 1999; 30: 651-657
        • Asakura Y
        • Ishibashi H
        • Ishiguchi T
        • et al.
        General versus locoregional anesthesia for endovascular aortic aneurysm repair: Influences of the type of anesthesia on its outcome.
        J Anesthesia. 2009; 23: 158-161
        • El-Hag S
        • Shafi S
        • Rosenberg M
        Local anesthesia-based endovascular repair of ruptured abdominal aortic aneurysm is associated with lower 30-day mortality in the National Surgical Quality Improvement Program database.
        J Vasc Surg. 2016; 63 (173-4S)
        • El-Hag S
        • Shafi S
        • Rosenberg M
        Decreased mortality with local vs general anesthesia in EVAR for ruptured abdominal aortic aneurysm in the Vascular Quality Initiative database.
        J Vasc Surg. 2016; 63 (147-8S)
        • Ioannou CV
        • Kontopodis N
        • Kehagias E
        • et al.
        Endovascular aneurysm repair with the Ovation TriVascular Stent Graft System utilizing a predominantly percutaneous approach under local anesthesia.
        Br J Radiol. 2015; 8820140735
        • Broos PPHL
        • Stokmans RA
        • Cuypers PWM
        • et al.
        Effects of anesthesia type on perioperative outcome after endovascular aneurysm repair.
        J Endovasc Ther. 2015; 22: 770-777
        • Yagan O
        • Ozyilmaz K
        • Tas N
        • et al.
        A retrospective analysis of comparison of general versus regional anesthesia for endovascular repair of abdominal aortic aneurysm.
        Turk J Anaesth Reanim. 2015; 43: 35-40
      3. Van Orden K, Farber A, Schermerhorn ML, et al. Local anesthesia for percutaneous endovascular abdominal aortic aneurysm repair is associated with fewer pulmonary complications [published online ahead of print March 27, 2018]. J Vasc Surg.

      4. Mouton R, Rogers CA, Harris RA, et al. Local anesthesia for endovascular aneurysm repair of ruptured abdominal aortic aneurysm. Br J Surg. 2018 First online 23 August 2018.

        • Reeves BC
        • Higgins JP
        • Ramsay C
        • et al.
        An introduction to methodological issues when including non-randomised studies in systematic reviews on the effects of interventions.
        Res Synth Methods. 2013; 4: 1-11
        • Deeks JJ
        • Dinnes J
        • D'Amico R
        • et al.
        Evaluating non-randomised intervention studies.
        Health Technol Assess. 2003; 2: 1-173
        • Hope K
        • Nickols G
        • Mouton R
        Modern anesthetic management of ruptured abdominal aortic aneurysms.
        J Cardiothorac Vasc Anesth. 2016; 30: 1676-1684
        • Holt PJ
        • Poloniecki JD
        • Khalid U
        • et al.
        Effect of endovascular aneurysm repair on the volume-outcome relationship in aneurysm repair.
        Circ Cardiovasc Qual Outcomes. 2011; 2: 624-632
        • Greenhalgh RM
        • Brown LC
        • Powell JT
        • et al.
        Endovascular versus open repair of aabdominal aortic aneurysm.
        N Engl J Med. 2010; 362: 1863-1871
        • Patterson BO
        • Hinchliffe RJ
        • Holt PJ
        • et al.
        Importance of aortic morphology in planning aortic interventions.
        J Endovasc Ther. 2010; 17: 73-77
        • Karthikesalingham A
        • Holt PJ
        • Hinchliffe RJ
        • et al.
        Risk of reintervention after endovascular aortic aneurysm repair.
        Br J Surg. 2010; 97: 657-663
        • Lewis SC
        • Warlow CP
        • Bodenham AR
        • et al.
        General anesthesia versus local anesthesia for carotid surgery (GALA): A multicenter, randomized controlled trial.
        Lancet. 2008; 372: 2132-2142
        • Paraskevas KI
        • Mikhailidis DP
        • Bell PR
        The GALA trial: Will it influence clinical practice?.
        Vasc Endovascular. 2009; 43: 429-432
        • Myles PS
        • Grocott MP
        • Boney O
        • et al.
        Standardizing end points in perioperative trials: Towards a core and extended outcome set.
        Br J Anaesth. 2016; 116: 586-589
        • Armstrong R
        • Mouton R
        Definitions of anaesthetic technique and the implications for clinical research.
        Anaesthesia. 2018; 73: 935-940
        • Wigmore TJ
        • Mohammed K
        • Jhanji S
        Long-term survival for patients undergoing volatile versus IV anesthesia for cancer surgery: A retrospective analysis.
        Anesthesiology. 2016; 124: 69-79