Intraoperative management: endovascular stents

Over the last two decades, the introduction of minimally invasive treatment options for a variety of vascular disease processes has made a dramatic contribution to the change in the practice of vascular surgery and anesthesia. The ability to treat pathology using both intraluminal and extraluminal methods has provided vascular surgeons, interventional radiologists, and cardiologists with unique treatment options that were not available less than a decade ago. Peripheral interventions to treat vascular disease have exploded from 90,000 in 1994 to more than 200,000 in 1997, and endovascular procedures have replaced nearly 50% of the traditional open vascular operations [1]. Intraluminal techniques, including balloon angioplasty, stenting, atherectomy, thrombectomy, and thrombolysis have been used for diagnostic and therapeutic management of a variety of vascular disorders. Endovascular grafts are being implanted in virtually any accessible artery in the body. Carotid artery stenting is becoming commonplace. Angioplasty and stenting are also used to improve blood flow through iliac, popliteal, and renal arteries, and even for transjugular intrahepatic portosystemic shunts. Stents have also been used to exclude dialysis catheter pseudoaneurysms [2], thereby potentially prolonging the functional life of arteriovenous fistulae. Most peripheral angioplasties and stents involve a low risk of bleeding and minimal hemodynamic stress, which may be treated with small doses of opioids or benzodiazepines. The latter two agents, in conjunction with local anesthesia for the arterial puncture and sheath placement, provide optimal circumstances for performing these procedures, the same anesthetic used daily, thousands of times, in cardiac catheterization suites. Moderate sedation can be given under the supervision of the radiologist, with rarely an anesthesiologist involved. In particular cases, notably carotid and aortic procedures (stenting of aneurysms and dissections), anesthesiologists are involved but for reasons other than to provide analgesia and sedation to the patient.