Anesthesia choice for frail patients undergoing endovascular repair of non-ruptured infrarenal abdominal aortic aneurysms.

Background: While general anesthesia is the predominant choice in endovascular aneurysm repair (EVAR), recent studies have suggested that locoregional anesthesia could be a viable alternative for suitable patients. Frailty has been identified as an independent predictor of elevated mortality and morbidity in EVAR. However, the choice of anesthesia in frail patients undergoing EVAR has not been explored.

Methods: This study aimed to compare the 30-day outcomes of non-emergent intact infrarenal EVAR in frail patients receiving either locoregional or general anesthesia. Patients who underwent infrarenal EVAR were identified in ACS-NSQIP database from 2012-2022. Frail patients were selected by 5-item Modified Frailty Index (mFI-5)≥2. Exclusion criteria included age<18 years, ruptured abdominal aortic aneurysm (AAA), emergency, and acute intraoperative conversion to open. A 1:1 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distal aneurysm extent, and concomitant procedures between patients under locoregional and general anesthesia. Thirty-day postoperative outcomes were evaluated.

Results: Among 16,438 patients who underwent EVAR, 4812 (29.27%) were frail. Among the frail patients, 483 (10.04%) were under locoregional anesthesia while 4,329 (89.96%) were under general anesthesia. After propensity-score matching, patients under locoregional or general anesthesia had comparable 30-day mortality (2.07% vs 2.48%, p=0.83) or any complications.

Conclusion: Locoregional and general anesthesia were found to have comparable postoperative outcomes in frail patients undergoing EVAR unruptured AAA, which did not align with the suggestion that locoregional anesthesia might be more advantageous in frail patients. While the patient's preferences should be considered, the choice of anesthesia should still be individualized to take into account the patient's age, comorbidities, AAA anatomy and the complexity of the case, as well as previous surgical and anesthesia experiences.