Thoracic Endovascular Aortic Repair (TEVAR) Periprocedural Care

Updated: Jan 12, 2021
  • Author: Thomas M Beaver, MD, MPH; Chief Editor: Dale K Mueller, MD  more...
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Periprocedural Care

Equipment

Hybrid operating rooms (ORs) provide optimal imaging technology for endovascular procedures such as thoracic endovascular aortic repair (TEVAR) and also are sufficiently large to accommodate open surgery in cases where it is required. The authors use the Artis zee system (Siemens Medical Solutions USA, Malvern, PA) in their hybrid OR (see the image below). Ceiling-mounted monitors showing the patient’s vital signs and preoperative computed tomography (CT) scans are recommended.

The authors use the Artis zee system (Siemens Medi The authors use the Artis zee system (Siemens Medical Solutions USA, Inc) in their hybrid operating room. Courtesy of Mark Herboth Photography, LLC, for the University of Florida.

The operating table should allow free access to the imaging C-arm below and should be long enough to accommodate the long guide wires that are used via the femoral artery access points.

Intravascular ultrasonography (IVUS) using a Volcano catheter (Volcano, San Diego, CA) is recommended to optimize graft placement in patients with challenging anatomy and in all patients with aortic dissection. 

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Patient Preparation

Anesthesia

Both general anesthesia and continuous spinal anesthesia have been used by the authors. Large-bore intravenous (IV) access for volume infusion is mandatory, along with continuous arterial pressure monitoring.

Spinal cord ischemia is a dreaded complication of TEVAR; therefore, spinal drains are used in patients undergoing this procedure. Drains are placed to drain at 10 mm Hg (15 cm H2O) for 24 hours and are then removed at 48 hours. One may reserve spinal drains for patients deemed to be at highest risk for spinal ischemia (eg, patients undergoing extensive coverage of the thoracic aorta and those with a history of prior abdominal aortic aneurysm [AAA] repair).

Vigilant monitoring for the development of neurologic deficits in the early postoperative period is essential. Delayed neurologic deficits can still be reversed with elevation of systemic arterial pressure and drainage of spinal fluid. [17]

Positioning

The patient remains in the supine position. When brachial artery access is required, the arms are placed at 90º angles and prepared and draped in the operating field.

Bilateral femoral artery access points are prepared along with the abdomen to the level of the nipples.

The entire field is covered with iodine-impregnated adhesive wrap.

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Monitoring & Follow-up

Over time, problems with stent grafts may arise (eg, kinking, migration, or leakage), and symptoms may or may not be experienced. Accordingly, lifelong routine surveillance with CT is warranted. [18] Most problems seen after repair can be managed with endovascular techniques.

At the time of discharge, follow-up appointments should be made for 1 month, 6 months, and 12 months from the date of repair, with a repeat CT scan obtained to evaluate the stent graft and the remodeling of the aorta around the graft. After the first 12 months, follow-up is typically done yearly. To ensure the most successful outcome after the procedure, it is crucial that patients comply with the follow-up plan provided.

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