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CARDIOVASCULAR ANESTHESIA

The Importance of Intraoperative Transesophageal Echocardiography in Endovascular Repair of Thoracic Aortic Aneurysms

Madhav Swaminathan, MD^*, Catherine K. Lineberger, MD^*, Richard L. McCann, MD, and Joseph P. Mathew, MD^*

Departments of *Anesthesiology and Surgery, Duke University Medical Center, Durham, North Carolina

Address correspondence and reprint requests to Madhav Swaminathan, MD, Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710. Address email to swami001{at}mc.duke.edu

Endovascular repair of the aorta (EVAR) is a promising alternative to open repair. Transesophageal echocardiography (TEE) is a sensitive imaging modality for aortic disease. We reviewed our experience with TEE in thoracic EVAR. Seven patients underwent thoracic EVAR under general anesthesia. Intraoperative angiography and TEE were used to identify the extent of the aneurysm and guide placement of the stent. Doppler color flow was used to supplement angiography to detect flow within the aneurysmal sac after stent placement. The endograft was successfully deployed in six patients. Endoleak was identified by TEE in three patients and confirmed by angiography in two of them. EVAR was abandoned in one patient on the basis of TEE findings of extensive aortic dissection. We found TEE to be a valuable intraoperative tool for 1) identifying aortic pathology, 2) confirming that the guidewire is in the true lumen, 3) aiding stent graft positioning, and 4) supplementing angiography for detecting endoleaks. TEE can supplement information obtained by angiography to enhance the accuracy of EVAR and potentially improve outcomes. The anesthesiologist is ideally positioned to provide the endovascular team with vital information regarding stent positioning, endoleaks, and cardiac performance with a single imaging modality.

IMPLICATIONS: Endovascular repair is an emerging alternative to open surgery for aortic aneurysms. We found transesophageal echocardiography to be a valuable imaging tool for guiding placement of the endograft, detecting leaks around the endograft, and supplementing information derived from angiography during endograft deployment.

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