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Thoracic endovascular aortic repair

O'Leary, Geraldine M. MSN, RN, FNP-BC

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doi: 10.1097/01.CCN.0000668568.61132.75
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Figure
Figure

Thoracic aortic disease affects 3 to 6 per 100,000 people per year, with thoracic aortic aneurysms (TAAs) accounting for approximately 25% of all aneurysms.1,2 According to the CDC, diseases of the aorta and its branches account for 43,000 to 47,000 deaths annually in the US.3 TAAs can be treated with open surgical repair or thoracic endovascular aortic repair (TEVAR).4 This article focuses on the indications and contraindications of TEVAR, diagnostic studies, the TEVAR procedure and complications, as well as nursing considerations and patient discharge instructions.

Anatomy of aneurysms

The aorta is the largest artery in the body and supplies oxygen, nutrients, and blood to all the vital organs. One of the most common problems affecting the aorta is an aneurysm. An aneurysm is an outpouching or dilation of a blood vessel that results from vessel wall weakening, which may occur in different areas of the aorta.5,6 A true aneurysm can be identified by its shape and is described as fusiform or saccular. The more common fusiform-shaped aneurysm bulges, or balloons out, on all sides of the blood vessel. A saccular-shaped aneurysm bulges, or balloons out, only on one side.5,6 (See Types of aortic aneurysms.)

Surgical intervention guidelines

A TAA is often asymptomatic and found on evaluation for an unrelated problem. The need for intervention is based on the size of the aneurysm.1 The overall goal is to prevent rupture.2 The American Heart Association/American College of Cardiology (AHA/ACC) guidelines recommend surgical referral when the aortic root, or the ascending aorta diameter, measures 5.5 cm or more. For aneurysms less than 4.0 cm in arch diameter, 12-month interval screening is recommended. Six-month intervals are recommended for aneurysms 4.0 to 5.4 cm in arch diameter.3

Indications

TEVAR was first described by Dake and colleagues in 1994 and was initially used in the treatment of descending aortic aneurysms.7 (See TEVAR.) Today, its use has expanded to include aortic arch aneurysms, penetrating atherosclerotic aortic ulcers, and traumatic aortic injury.8-10 The advantages of TEVAR over traditional open surgical repair include decreased perioperative blood loss, operative time, and morbidity, and shorter ICU and hospital stays.11-15

Figure
Figure:
Types of aortic aneurysms

Contraindications

Other than a known allergy to any of the components used in a stent graft, there are no absolute contraindications for TEVAR. Relative contraindications to consider include extremely tortuous, calcified or small femoral or iliac arteries; curvature or kinking of the aortic arch segment; infection; and underlying connective tissue disease such as Marfan syndrome or Loeys-Dietz syndrome.10,13 According to the AHA/ACC guidelines, patients with connective tissue disorders and without significant comorbidities should undergo open repair.1,3 Another relative contraindication to consider is the patient's ability to comply with the follow-up surveillance necessary after the procedure.12

Diagnostic studies

The initial evaluation of a patient with a TAA includes a complete health history and physical assessment by the cardiovascular surgeon and cardiologist. ECG, chest X-ray, and lab studies are also obtained.2 Computed tomography angiography (CTA) is the mainstay of evaluation, with the ability to measure aneurysm dimensions, the diameters and lengths of the abdominal and pelvic arteries, as well as identify extensive thrombus or calcifications.1,12

TEVAR procedure

A hybrid OR, which is outfitted with a full complement of OR equipment plus state-of-the-art imaging technology, is used for the TEVAR procedure in order to provide high-definition radiographic imaging and a mobile table. The patient, placed under general anesthesia and controlled ventilation, is positioned with groins, abdomen, and chest exposed.16 A radial artery catheter is placed to monitor systemic BP. The femoral artery is then accessed with an angiographic sheath, and a rigid guidewire is advanced to the ascending aorta under fluoroscopy.10,16 If needed, an angled glide catheter can steer the guide wire into the ascending aorta. A pigtail catheter inserted via the femoral artery is used to perform an aortogram. After the aortogram, the proximal neck is evaluated. The length and diameter of the proximal and distal neck are measured using the preoperative CTA, an intravascular ultrasound, and the aortogram.17 The stent graft is chosen based on these measurements.10 Selection of the optimal stent graft size is of critical importance in minimizing the risk of endoleak formation, migration, retrograde type A aortic dissection, and rupture.10,18 The stent graft is made of a high-density, multifilament polyester graft material that has low porosity.19 One stent or multiple overlapping stents can be used for greater coverage depending on aneurysm size.

The patient is heparinized to an activated clotting time (ACT) of more than 200 seconds to prevent clot formation.17 Then the stent graft is flushed with heparinized solution and advanced into the proximal neck. A repeat angiogram is recommended to confirm the positioning of the device within the aorta.17

During device expansion, the systolic BP is lowered to 60 mm Hg using sodium nitroprusside to obtain precise deployment of the device and avoid migration due to forward blood flow. Adenosine may be administered to gain a 4- to 5-second cardiac arrest or a transfemoral venous pacing wire can be used for rapid pacing to prevent ejection of forward blood flow.13 The ventilator is also stopped shortly for device deployment in endotracheally intubated patients to eliminate motion artifact.17

After deployment, the stent graft is ballooned to decrease the possibility of endoleak.17 The nonocclusive balloon reduces movement of the graft, which can happen with the BP pushing forward. A final aortogram is then performed to confirm that endoleak has not occurred.16 Distal pulses of the lower extremities are assessed to confirm a return to preoperative baseline and rule out any embolic events. The endovascular wires/catheters are then removed, the arteriotomy is repaired or closed with a closure device, and the patient is transferred to the ICU for frequent neurologic and vascular assessments to detect complications such as stroke, spinal cord ischemia, or lower extremity ischemia.17,20

Figure
Figure:
TEVAR

Complications

Although there are advantages of TEVAR compared with traditional open repair, many potential complications still exist. These include spinal cord ischemia, stroke, renal complications, aortoesophageal fistula (AEF) and aortobronchial fistula (ABF), retrograde type A dissections, postimplantation syndrome, ischemic bowel, and endoleak.9,11,15,21

Spinal cord ischemia. Spinal cord ischemia is thought to result from the interruption of the blood supply to the spinal cord, which may occur during deployment of the stent graft. (See Spinal cord ischemia risk factors.) An endovascular approach may damage the iliac arteries and compromise collateral flow to the anterior spinal artery.9 The incidence of spinal cord ischemia ranges from 2.5% up to 8% and remains a concern.2 Several factors may increase the risk of spinal cord ischemia.9 Most patients who develop spinal cord ischemia will do so within 24 hours of the procedure, with a median onset of 10 to 13 hours.22 Preventive strategies include maintenance of mean arterial pressure (MAP), the prevention of high intrathecal pressure through the use of lumbar drains, and the avoidance of high central venous pressures.21,23

Stroke. The incidence of stroke in patients undergoing TEVAR ranges from 1.2% to 6.9%.9 As the TEVAR procedure becomes more advanced and grafting extends into the aortic arch, the risk of stroke for these patients will increase further.24 During the procedure, guidewires within the aortic arch can potentially mobilize debris resulting in an embolic ischemic stroke.2 Stent deployment is associated with numerous microemboli.25 Thus, patients are typically anticoagulated during the procedure and are maintained within therapeutic range using ACT monitoring.9 Postoperative anticoagulation should be held if the patient has a lumbar drain in place to reduce the possibility of epidural hematoma; however, venous thromboembolism (VTE) prophylaxis is routine.8,26

Renal complications. Many patients with thoracic aneurysms often have chronic kidney disease. Contrast-induced nephropathy (CIN) and hypotensive injuries may result in further damage to renal function.2,27 Renal complications have been associated with a seven- to ninefold mortality increase in patients with TAA repairs.27,28 Patients undergoing TEVAR require lifelong surveillance imaging with repeated contrast exposure to identify endoleak and graft migration.9 Therefore, the management of CIN in these patients remains complex.

Hydration with sodium bicarbonate has been used to try to reduce CIN. Other proposals for management of these patients include stopping all angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers 48 hours prior to TEVAR, admitting patients with a creatinine greater than 2.0 mg/dL (normal serum creatinine level 0.5 to 1.2 mg/dL) for hydration preoperatively, minimizing iodinated contrast media and/or using low or iso-osmolar contrast agents when possible, and avoiding nephrotoxic agents.5,28 The use of N-acetylcysteine, which is sometimes used to decrease renal complications in patients undergoing cardiac catheterization, has not been proven effective in TEVAR.9 These patients require complex management pre- and postoperatively.

Table
Table:
Spinal cord ischemia risk factors9

AEF and ABF. Although rare, AEF and ABF are devastating complications for patients undergoing TEVAR.2,9,29,30

AEF is a fistula between the esophagus and the aorta that presents as mid-thoracic chest pain, with a small episode of hematemesis followed by a brief interval, before massive hematemesis and exsanguination occur.29 Patients may also present with new-onset fever, fatigue, and anorexia.9 If an AEF is suspected, an emergent CTA and esophagogastroduodenoscopy should be obtained.2,29 Treatment with an endograft is the first-line therapy to stop exsanguination and limit bacterial contamination until surgery can be performed.9,29 Surgical interventions range from graft resection and replacement to esophagectomy but mortality remains very high for these patients.31

ABF is a fistula between the thoracic aorta and the adjacent pulmonary parenchyma or tracheobronchial tree.30 ABF presents with either intermittent or massive hemoptysis and is nearly always fatal if not diagnosed or treated promptly.9,30 If suspected, a CTA should be obtained and emergent surgery performed.9

Retrograde type A dissections. Aortic dissection results from a tear in the intima (inner lining) of the aorta. Because of the high pressure in the aorta, blood enters the media (middle layer) at the point of the tear and causes the tear to extend in either a forward direction (with the flow of blood) called anterograde dissections or in a backward direction (opposite the flow of blood) called retrograde dissections. Aortic dissections are further classified based on the site of the original tear (Debakey classification) and whether it involves the ascending aorta (Stanford classification).1 Type A dissection affects the ascending aorta and arch, requiring immediate surgery, while Type B dissection begins in the descending aorta and may be managed conservatively.6,14

Retrograde type A aortic dissection is a rare but potentially fatal complication of TEVAR with an incidence of 1.3% to 3.4% and reported mortality of 42% to 57%.32 Retrograde dissection may occur intraoperatively or up to 7 years post procedure.32 Frequently, intraoperative diagnosis is made based on angiography or thoracic endovascular echocardiography.33 Dissection has been attributed to trauma from the deployment of the endograft into a diseased vessel as well as from wear and tear associated with the perpetual movement of the beating heart.33 Clinically, patients most commonly present with new-onset chest pain or syncope and require an immediate CTA or magnetic resonance angiography (MRA). Once identified, these patients need emergent open surgical repair.9,33

Postimplantation syndrome. Postimplantation syndrome is an inflammatory response following aortic repair that results in fever and malaise and often includes leukocytosis and elevation of inflammatory mediators such as C-reactive protein.8,9 The clinical significance of this syndrome is not currently known and is often indistinguishable from an infection. It was initially thought to be a self-limiting reaction that resolves within 2 weeks of implantation; however, these patients have increased rates of renal insufficiency, prolonged lengths of stay, and higher mortality.8,9,26 Further studies are needed to establish diagnostic criteria and treatment guidelines.

Ischemic bowel. Mesenteric complications may result from aortic dissection or from emboli released during manipulation of the aorta during repair.2 Occlusion of the superior mesenteric artery can cause ischemia of the small bowel. Although rare, this complication should be considered in any patient with elevated serum lactate levels or severe abdominal pain. If suspected, an exploratory laparoscopic exam of the peritoneal cavity should be performed.2 Endovascular stenting, open surgical superior mesenteric artery bypass, and/or surgical thrombectomy may be needed for reperfusion.9 Prognosis for these patients is grave and often results in hospital death.2

Endoleak. Endoleak is a complication of TEVAR that can happen at any time. It is defined as the persistence of blood flow outside the lumen of the graft in a segment treated by the graft, as determined by an imaging study.34 Incidence ranges from 5% to 25% at 30 days and 4% to 28% at 1 year with about 46% requiring additional treatment endovascularly.35 (See Types of endoleak.)

Types I and II are considered “high pressure” and require intervention. The presence or absence of an enlarging aneurysm sac strongly influences the decision to pursue or not pursue treatment.9 Type III endoleak is currently less common due to the improvements in grafts used today. A defective device, damage during delivery or balloon manipulation, or constant wear of the fabric against the endograft wires indicates the need for another endograft.9

Follow-up imaging surveillance of patients is done at 30 days, 6 months, 12 months, and then yearly to screen for endoleak post TEVAR.9,13 Since this requires significant doses of ionizing radiation with CTA and repeated exposure to contrast medium, ultrasound, and MRA without I.V. contrast, this may play a role in future surveillance protocols.9

Postoperative nursing considerations

Because of the multiple serious complications that can occur after a TEVAR, a positive outcome for the patient relies on vigilant postoperative nursing assessments and prompt interventions.

Neurologic assessment. Neurologic assessments are usually performed hourly for 8 hours and then every 2 hours, but can vary by institution.37 The assessment includes the Glasgow Coma Scale score, lower extremity strength, and pupil reaction.38 Assess the patient for signs and symptoms of meningeal irritation (stiff neck, headache, nausea, vomiting, photophobia) and report to the provider immediately.38 If the patient reports a headache, develops new neurologic deficits, or experiences a change in level of consciousness, the physician should be notified immediately.11,37 If signs of brainstem herniation are suspected (decrease in level of consciousness, irritability, confusion, abnormal posturing, and abnormal breathing pattern), activation of the emergency response team may be required.11

Assess for signs of embolic stroke, such as unilateral sensory or motor loss, amaurosis fugax (temporary loss of vision in one or both eyes due to a lack of blood flow to the retina), and aphasia, as well as changes in mentation or level of consciousness, facial symmetry, and pupil responses.12,38 Patients should receive VTE prophylaxis as prescribed.12

Table
Table:
Types of endoleak9,36

Hemodynamic monitoring. In the immediate postoperative period, management of intravascular volume and systemic BP is essential. If the BP is too high, anastomotic leaks or graft migration may occur. On the other hand, hypotension may cause spinal ischemia, compromised renal perfusion, or infarction of vital organs.5,11,12 The MAP goal is usually kept between 75 and 85 mm Hg.9 However, the MAP goal should be obtained from the surgeon as it may be increased or decreased depending on the patient's response. If needed, a low MAP can be treated with I.V. colloids (albumin), crystalloids (Ringer's lactate solution), or neosynephrine.8 A high MAP can be treated with sodium nitroprusside, alpha-1 adrenergic antagonists, and nonselective beta-blockers as needed.2

Pulmonary assessment. The critical care nurse should assess the patient's pulmonary status and begin weaning the patient from the mechanical ventilator, if required, as soon as possible. It is important to evaluate the patient's spontaneous breathing capability, respiratory rate, and respiratory pattern.6 Arterial blood gases should also be obtained and monitored per unit protocol. Oxygen saturation should be greater than 90% by pulse oximetry.6 Instruction on the use of the incentive spirometer is also important to help prevent atelectasis or pulmonary infection and should be encouraged every hour while awake after extubation.

Pain management. Keeping the patient comfortable postoperatively is also a high priority for the critical care nurse. Adequate pain management helps keep BP and heart rate under control. Pain should be assessed routinely, as persistent pain may indicate aortic dissection or impending rupture.2,11

Peripheral vascular assessment. Assessing the neurovascular status of the lower extremities and monitoring the access sites for bleeding and hematoma is another important component of the nursing assessment.11 Assess for the classic signs of acute limb ischemia using the six “Ps”: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.38 Note the return of lower extremity movement, sensation, and strength after waking from anesthesia. If acute limb ischemia is suspected, contact the healthcare provider immediately. Ischemia may progress to tissue necrosis and gangrene within a few hours.38

Gastrointestinal and renal assessments. Abdominal assessment and monitoring of urine output is important because embolization can occur to the visceral and renal arteries. Nursing interventions include measurement and monitoring of intra-abdominal pressure and monitoring for signs and symptoms of acute ischemic bowel. Contact the surgeon immediately if the patient experiences severe abdominal pain, nausea, vomiting, or diarrhea in the absence of abdominal distension. Check the patient's lactate level for worsening metabolic acidosis indicating hypoperfusion to the gut.2,12 Assess the patient's hydration status and serum electrolyte results and closely monitor urine output.39 Additional abdominal radiologic imaging may be needed.12

Consideration of postoperative nutritional requirements is also necessary. When the patient has fully recovered from anesthesia and bowel sounds have returned, ice chips may be introduced before advancing to clear liquids and finally solids as tolerated.12 The American Society for Parenteral and Enteral Nutrition guidelines recommend starting enteral nutrition for all appropriate patients within 24 to 48 hours of admission to the ICU. If hemodynamic instability or high vasopressor needs prohibit enteral feeding after 7 days, parenteral feeding may be required.8,40

Site infection. The nurse should assess all incision sites for signs and symptoms of infection, which include erythema, warmth, edema, and drainage.6 Monitor for leukocytosis daily. The patient's temperature should also be assessed every 2 hours, or per the unit protocol. Meticulous incisional care should be performed by the critical care nurse to prevent infection.

Patient and family support. Often, aortic pathologies are emergent situations. Seeing their loved one in such a condition can be upsetting to family members. Critical care nurses can support families by providing information, interpreting medical terminology, and explaining procedures. When critical care nurses communicate information in a caring and compassionate manner, it significantly enhances the well-being of the family.40 The critical care nurse is often the liaison relaying feedback between the medical staff and the family, recommending family meetings as necessary.

Patient discharge instructions

Teach the patient to monitor the access sites for signs of infection or bleeding. Review pain management strategies with the patient and family. Explain to the patient that sodium can affect their BP control, so they should try to maintain a low-sodium diet. Instruct the patient to walk at least four times a day and avoid lifting more than 10 lb (4.5 kg) for 2 weeks. Driving can resume 2 weeks after discharge. Teach patients to seek care immediately if they have a sudden decrease in strength, sensation, temperature, or experience a change in color of the lower extremities, sudden swelling and acute pain in one or both groins, and/or sudden onset of chest or back pain.12

The critical care nurse should also stress the importance of monitoring of the stent graft by CTA at 1 month, 6 months, and 12 months after implant, and then annually.12,13 The nurse should explain that the stent graft is not a cure and complications, such as endoleak, may arise in the future, which could require a second endovascular procedure. Stressing adherence to the annual surveillance is paramount.

Conclusion

Although TEVAR has emerged as the treatment of choice for patients with TAAs, it is still a high-risk procedure with many complex complications that contribute to high morbidity and mortality. Knowledgeable critical care nurses are instrumental in the proper care, recovery, and discharge of patients who have undergone a TEVAR.

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    Keywords:

    aorta; aortic dissection; endoleak; fistula; stent graft; thoracic aortic aneurysm (TAA); thoracic endovascular aortic repair (TEVAR)

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