Anaesthesia for abdominal aortic surgery--a review (Part II)

Patients presenting for abdominal aortic surgery have a high incidence of vascular disease elsewhere, manifested primarily by hypertension, coronary and cerebrovascular disease, as well as co-existing respiratory, renal and metabolic disorders. Routine clinical assessment, electrocardiogram, chest roentgenograms, resting and exercise radionuclide ventriculography and echocardiography, dipyrdiamole-thallium scanning are all designed to assess the functional status of the myocardium and to detect the presence of significant coronary artery disease. Patients with no abnormalities on physical examination, routine evaluation and no redistribution on dipyridamole-thallium scanning should proceed to surgery with the expectation of very low perioperative cardiac risk. Patients with evidence of coronary artery disease and significant redistribution on dipyridamole-thallium scan should undergo coronary angiography and possible myocardial revascularization before definitive aortic vascular surgery. For high cardiac risk patients with no bypassable lesions presenting for abdominal aortic aneurysm resection a conservative policy of serial three monthly ultrasound or CT assessment may be adopted, with selective resection for rapid aneurysm expansion or symptom development. A variety of extra-anatomical and angioplastic techniques is available for similar high cardiac risk patients with aortoiliac occlusive disease. The haemodynamic consequences of aortic cross-clamping, especially in aneurysm patients, include a significant reduction in stroke volume, cardiac index, and myocardial oxygen consumption with an increased systemic vascular resistance. Patients with coronary artery disease may respond to aortic cross-clamping by increasing pulmonary capillary wedge pressure and by demonstrating ECG evidence of myocardial ischaemia. Pulmonary artery catheterization is especially indicated in patients with a history of previous myocardial infarction, angina or signs of cardiac failure and in patients with evidence of diminished ejection fraction, abnormal ventricular wall motion or myocardial redistribution on preoperative scanning. The more widespread application of intraoperative transoesophageal two-dimensional echocardiography and radionuclide cardiography monitoring techniques into anaesthetic practice will enable measurement of left ventricular dimensions, myocardial performance and wall motion. Suggested guidelines for anaesthetic management are presented in Table VI. A combined opiate-oxygen-volatile anaesthetic agent technique will best ensure a hypodynamic circulation with preservation of myocardial oxygenation.(ABSTRACT TRUNCATED AT 400 WORDS)