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Original Investigation |

Combined Epidural-General Anesthesia vs General Anesthesia Alone for Elective Abdominal Aortic Aneurysm Repair ONLINE FIRST

Amit Bardia, MBBS1; Akshay Sood, MD2,3; Feroze Mahmood, MD4; Vwaire Orhurhu, MD, MPH4,5; Ariel Mueller, MA4; Mario Montealegre-Gallegos, MD4; Marc R. Shnider, MD4; Klaas H. J. Ultee6; Marc L. Schermerhorn, MD6; Robina Matyal, MD4
[+] Author Affiliations
1Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
2Center for Outcomes Research, Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan
3Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
4Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
5Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
6Department of Vascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
JAMA Surg. Published online September 07, 2016. doi:10.1001/jamasurg.2016.2733
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Importance  Epidural analgesia (EA) is used as an adjunct procedure for postoperative pain control during elective abdominal aortic aneurysm (AAA) surgery. In addition to analgesia, modulatory effects of EA on spinal sympathetic outflow result in improved organ perfusion with reduced complications. Reductions in postoperative complications lead to shorter convalescence and possibly improved 30-day survival. However, the effect of EA on long-term survival when used as an adjunct to general anesthesia (GA) during elective AAA surgery is unknown.

Objective  To evaluate the association between combined EA-GA vs GA alone and long-term survival and postoperative complications in patients undergoing elective, open AAA repair.

Design, Setting, and Participants  A retrospective analysis of prospectively collected data was performed. Patients undergoing elective AAA repair between January 1, 2003, and December 31, 2011, were identified within the Vascular Society Group of New England (VSGNE) database. Kaplan-Meier curves were used to estimate survival. Cox proportional hazards regression models and multivariable logistic regression models assessed the independent association of EA-GA use with postoperative mortality and morbidity, respectively. Data analysis was conducted from March 15, 2015, to September 2, 2015.

Interventions  Combined EA-GA.

Main Outcomes and Measures  The primary outcome measure was all-cause mortality. Secondary end points included postoperative bowel ischemia, respiratory complications, myocardial infarction, dialysis requirement, wound complications, and need for surgical reintervention within 30 days of surgery.

Results  A total of 1540 patients underwent elective AAA repair during the study period. Of these, 410 patients (26.6%) were women and the median (interquartile range) age was 71 (64-76) years; 980 individuals (63.6%) received EA-GA. Patients in the 2 groups were comparable in terms of age, comorbidities, and suprarenal clamp location. At 5 years, the Kaplan-Meier–estimated overall survival rates were 74% (95% CI, 72%-76%) and 65% (95% CI, 62%-68%) in the EA-GA and GA-alone groups, respectively (P < .01). In adjusted analyses, EA-GA use was associated with significantly lower hazards of mortality compared with GA alone (hazard ratio, 0.73; 95% CI, 0.57-0.92; P = .01). Patients receiving EA-GA also had lower odds of 30-day surgical reintervention (odds ratio [OR], 0.65; 95% CI, 0.44-0.94; P = .02) as well as postoperative bowel ischemia (OR, 0.54; 95% CI, 0.31-0.94; P = .03), pulmonary complications (OR, 0.62; 95% CI, 0.41-0.95; P = .03), and dialysis requirements (OR, 0.44; 95% CI, 0.23-0.88; P = .02). No significant differences were noted for the odds of wound (OR, 0.88; 95% CI, 0.38-1.44; P = .51) and cardiac (OR, 1.08; 95% CI, 0.59-1.78; P = .82) complications.

Conclusions and Relevance  Combined EA-GA was associated with improved survival and significantly lower HRs and ORs for mortality and morbidity in patients undergoing elective AAA repair. The survival benefit may be attributable to reduced immediate postoperative adverse events. Based on these findings, EA-GA should be strongly considered in suitable patients.

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Figure 1.
Criteria for Patient Inclusion

Patients who underwent elective, open abdominal aortic aneurysm (AAA) surgery from 2003 to 2011 were assessed using the Vascular Society Group of New England database. EA indicates epidural anesthesia; GA, general anesthesia.

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Figure 2.
Survival and Use of Combination Epidural and General Anesthesia (EA-GA) for Abdominal Aortic Aneurysm (AAA) Surgery

A, Survival after AAA surgery stratified according to EA use. Kaplan-Meier estimates with 95% Hall-Wellner CI bands; patients who received EA-GA had lower all-cause mortality (26%; 95% CI, 24% to 28%) compared with those who received GA alone (35%; 95% CI, 32% to 38%) at 5 years (log-rank P < .01). B, No change in EA-GA utilization rates was observed for elective, open AAA surgery during the 9-year study period. Annual estimated percentage change, −2.4% (95% CI, −5.1% to 0.4%; P = .13).

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