Open conversion abdominal aortic endograft in thoracic epidural anesthesia alone in patient with severe copd: a case report of surgery in awake patient

Introduction A 79-year-old male was referred, with open abdomen surgical indication, for an asymptomatic iuxtarenal abdominal aortic aneurysm and type I endoleak with distal migration of an endovascular aortic – bisiliac prosthesis, after an endovascular correction done eight years before. This patient has severe COPD (Stage IV and oxygen dependent), new onset of renal failure (G4 KDIGO CKD classification), systemic arterial hypertension and severe peripheral vasculopathy. General anesthesia is not safe, because of the elevated perioperative risks of severe respiratory complications. We have decided for an awake surgery with an epidural anesthesia. Operative risks were assessed with the patient who accepted intervention. Methods Anesthesiologic Management Patient has been conducted in operating room, where 2 large bore peripheral vein have been placed. Arterial catheter and advance cardiac output monitoring through radial artery has been established. A 19 Gauge epidural catheter was placed, through 17 Gauge Tuohy needle, in T9-T10 space and advanced for 5 cm in the epidural space. Epidural anesthesia induction has been obtained with bolus of Ropivacaine 0,5% 10 mL (50 mg) and Morphine 1 mg bolus. Ropivacaine 0,2% 4 mL/h epidural infusion has been started at the skin incision. After surgical isolation of aortic aneurysm, we have administered ropivacaine 0.5% 5 ml (25 mg) and lidocaine 2% 3 ml (60 mg) boost. Patient was maintained on spontaneous breathing with 3L/min oxygen supplementation through nasal cannula achieving peripheral oxygen saturation between 94% - 95%. Surgical Management A supra and sub-umbilical laparotomy was made (cut about 20 cm) with a retroperitoneum incision and iuxtarenal aorta isolation up to the iliac bifurcation. The endoprosthesis was removed and aneurysmectomy performed. Total clamp time was 48 minutes. Results The patient tolerated well the surgical procedure. Hemodynamic was stable during all the procedure. At the end of surgery patient was recovered in Intensive Care Unit for 24 hours. No major event has occurred during ICU admission, so the patient was discharged the day after surgery. Total hospital stay was 10 days. Discussion In literature, awake aortic surgery procedures have already been described. Novelty of our case is nor retroperitoneal approach, nor mini laparotomy surgical technique were suitable. We performed a thoracic epidural technique alone with laparotomic transperitoneal approach. Open abdomen aortic aneurysm morbidity and mortality vary from 12% to 26% and 4% to 6%, respectively. The association of epidural anesthesia (EA) with general anesthesia (GA) is linked to improved survival if compared to GA alone. The hemodynamic effects of EA maintain their benefits also when EA is used alone, as in our case. In fact, EA causes modulation of spinal sympathetic outflow and vasodilation with consequent reduction of left ventricle afterload and improved organ perfusion.