Anesthetic Considerations for Aneurysmal Embolization in the Radiology Suite

During the last years, endovascular ablation of aneurysms has become a popular alternative to the classic surgical approach. Recent studies show a similar, or even improved, outcome after endovascular aneurysmal therapy (83,84 ). The definitive roles of microsurgical and endovascular treatments, however, remain to be defined, as only future follow-up studies of the two treatment paradigms will be able to evaluate the long-term risk for rerupture and rebleeding, the necessity for repeat procedures, and the long-term development of neurologic function and subsequent quality of life (85,86) . During an endovascular aneurysmal procedure, the goals of anesthetic management are as follows: (i) comprehensive management during the course of the intervention, including safe transport between the radiology suite and the ICU, (ii) providing for patient immobility and tolerance of the procedure, (iii) providing physiologic homeostasis throughout, (iv) manipulating systemic and CBF, (v) controlling anticoagulation, (vi) managing all unexpected procedural complications, and (vii) allowing rapid recovery after the procedure.

The best anesthetic technique is a matter of controversy (87). Some centers use IV sedation, and others request general anesthesia for these procedures; but no scientific evidence suggests that one technique over the other improves outcome. Frequently, patients require general anesthesia, including endotracheal intubation, because advancement of the endovascular instruments requires the patient's head and neck to be in a neutral position, which, in turn, might compromise the airway of a moderately sedated patient. Moreover, the procedure is very sensitive to motion artifacts, and it is not likely that a patient will tolerate a long period of lying supine and remaining motionless throughout. Even small head and neck movements elicited by spontaneous breathing can compromise the therapeutic result. In addition, general anesthesia might improve the tolerance of short, deliberate interruptions of cerebral perfusion, sometimes necessary to allow placement and securing of embolic material. Some teams provide short cardiac pauses by application of escalating doses of adenosine to allow a short (10-20 sec) cessation of cerebral perfusion (88). The introduction of Guglielmi detachable coils (2) for embolization has reduced the need for profound hypotension during neuroradiologic aneurysmal repair.

The anesthesiologist also plays an important role during the management of procedure-related crises. For example, in case of an accidental aneurysmal perforation, the anesthesiologist must provide rapid reversal of anticoagulation to minimize aSAH. Similarly, if embolic material is displaced and threatens to occlude cerebral vessels, the blood pressure might need to be increased immediately to improve collateral blood flow. The respective drugs should be prepared and available at all times.

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