1. Clinical Research
Postoperative Pulmonary Function After
Open Abdominal Aortic Aneurysm Repair in
Patients With Chronic Obstructive
Pulmonary Disease: Epidural Versus
Intravenous Analgesia
Venetiana Panaretou,1 Levon Toufektzian,2 Ioanna Siafaka,3 Irene Kouroukli,1
Fragiska Sigala,2 Charalambos Vlachopoulos,4 Stilianos Katsaragakis,2 George Zografos,2
and Konstantinos Filis,2 Athens, Greece
Background: We reviewed our experience to determine the effect of epidural versus intrave-
nous analgesia on postoperative pulmonary function and pain control in patients with chronic
obstructive pulmonary disease (COPD) undergoing open surgery for abdominal aortic
aneurysm.
Methods: A retrospective study with prospective collection of data of 30 COPD patients under-
going open abdominal aortic aneurysm repair, during a 5-year period. Group I (n ¼ 16) was oper-
ated under combined general and epidural anesthesia and epidural analgesia; group II (n ¼ 14),
under general anesthesia and intravenous analgesia. All patients performed pulmonary function
tests (PFTs) preoperatively and during postoperative days 1 and 4. Pain assessment was per-
formed on all patients during rest and activity on postoperative days 1, 2, and 4 by using the
visual analog scale. Data were recorded for PFTs, postoperative pain, length of hospital stay,
length of ICU stay, and postoperative pulmonary morbidity, including atelectasis and pulmonary
infections.
Results: There was no in-hospital mortality. Hospital stay was similar between the two
groups (group I: 7.1 ± 1.0, group II: 7.5 ± 1.1). Group I patients showed significantly
increased postoperative PFT values compared with group II patients at all time points (post-
operative day 1: FEV1(%): 32.3 ± 4.4 vs. 27.1 ± 1.6, p ¼ 0.007, FVC(%): 35.4 ± 8,5 vs.
28.3 ± 2.3, p ¼ 0.035; postoperative day 4: FEV1(%): 50.4 ± 6.8 vs. 41.9 ± 6.8, p ¼
0.017, FVC(%): 51.3 ± 8.3 vs. 43.0 ± 7.9, p ¼ 0.046). However, postoperative clinical
pulmonary morbidity was not different between groups. Group I patients showed signifi-
cantly reduced postoperative pain at all time points compared with group II patients. These
differences were more pronounced during postoperative days 1 and 2, both at rest (visual
analog score: 1.1 ± 0.9 vs. 2.6 ± 1.6, p ¼ 0.02 and 0.7 ± 0.8 vs. 1.9 ± 1.1, p ¼ 0.021,
respectively) and during activity (2.3 ± 0.8 vs. 4.0 ± 1.7, p ¼ 0.013 and 1.6 ± 0.7 vs.
2.8 ± 1.2, p ¼ 0.019, respectively).
1
Department of Anesthesiology, Hippokration Hospital, Athens, Greece. Correspondence to: Konstantinos Filis, MD, PhD, Division of
2
Division of Vascular Surgery, First Department of Propeudetic Vascular Surgery, First Department of Propeudetic Surgery, Hippokra-
Surgery, Hippokration Hospital, Medical School, University of Athens, tion Hospital, Medical School, University of Athens, 34B Faneromenis
Athens, Greece. Street, 15562 Athens, Greece; E-mail: kfilis@hotmail.com
3
Department of Anesthesiology, Aretaieio Hospital, Medical School, Ann Vasc Surg 2012; 26: 149–155
University of Athens, Athens, Greece. DOI: 10.1016/j.avsg.2011.04.009
4 Ó Annals of Vascular Surgery Inc.
First Department of Cardiology, Hippokration Hospital, Medical Published online: October 24, 2011
School, University of Athens, Athens, Greece.
149

2. 150 Panaretou et al. Annals of Vascular Surgery
Conclusions: Epidural anesthesia and postoperative epidural analgesia improve the postoper-
ative respiratory function, compared with general anesthesia and systemic analgesia, and
reduce postoperative pain as well, in COPD patients undergoing elective infrarenal abdominal
aortic aneurysm repair.
INTRODUCTION opted to assess the effect on pain management and
postoperative pulmonary function in this high-risk
Although various developments and refinements in group of patients.
surgical techniques and anesthetic approaches have
reduced perioperative risk, abdominal aortic aneu-
rysm (AAA) open repair in patients with severe
chronic obstructive pulmonary disease (COPD) METHODS
continues to be a high-risk procedure associated
Study Group
with life-threatening complications and increased
perioperative morbidity.1 In addition, COPD has Among 110 patients electively operated for an
been associated with an increased prevalence of infrarenal AAA (max diameter> 55 mm), during
AAA2,3 and is an independent factor for AAA a 5-year period (2004-2009), we reviewed 30
rupture.4 Obviously, endovascular AAA repair has patients with severe COPD. Operations were per-
been now established as the treatment of choice formed by the standard transperitoneal exposure,
for this high-risk group of patients. However, endo- by the same vascular surgical and anesthesia
vascular repair is feasible in less than 60% of teams. None of these patients fulfilled criteria for
patients5; therefore, a number of AAA patients endovascular aneurysm repair (in 18 cases due to
with COPD will still remain under medical observa- short aortic neck, in 12 due to iliac access prob-
tion, waiting to undergo open AAA repair until it lems). We excluded emergency cases, patients
becomes feasible in their case. Recent studies have with severely impaired left ventricular systolic
shown that perioperative morbidity and mortality function with ejection fraction <30%, patients
as well as long-term survival of these patients justify with a history of cerebrovascular accident or of
open AAA repair,6 although different clinical renal and hepatic insufficiency, and patients
predictors (mainly cardiac and renal disease) of allergic to levobupivacaine.
severe morbidity and an unfavorable outcome Pulmonary disease was diagnosed by clinical
exist.7 history and PFTs. Smoking history was present in
A vast amount of literature underscores the bene- all patients. PFTs, including forced vital capacity
ficial effects of epidural anesthesia and analgesia in (FVC) and forced expiratory volume in 1 second
improving pain management and enhancing post- (FEV1), were measured preoperatively in all
operative recovery in comparison with general patients by using a portable spirometer unit (Spiro-
anesthesia alone.8e10 Epidural anesthesia and post- lab II, SDI Diagnostics, Rome, Italy). With a good
operative epidural analgesia attenuate reductions in flow-volume loop, each measurement was per-
respiratory parameters during the postoperative formed three times, and the best trial was recorded.
period, as compared with systemic analgesia in The diagnosis of moderate to severe COPD was
patients undergoing abdominal vascular proce- defined by the presence of one or more of the
dures.11 Although epidural anesthesia has been following criteria: PaCO2 >45 mmHg, FEV1 <70%
the common practice for open AAA repair, this prac- of predicted value, and FEV1/FVC <0.7, as the
tice comes largely from experience in abdominal same limits have been used by a network of interna-
and thoracic surgery. Thus, it has not been tional experts.12 Patients were assigned to receive
adequately studied in COPD patients undergoing either combined general and epidural anesthesia
open AAA repair in terms of postoperative respira- and epidural postoperative analgesia (group I, n ¼
tory function, as evidenced by alterations in pulmo- 16), or general anesthesia alone with postoperative
nary function tests (PFTs). patient-controlled intravenous systemic analgesia
The objective of this study was to compare respi- (group II, n ¼ 14). Preoperatively, all patients
ratory effects of combined general and epidural received bronchodilator treatment with salbutamol
anesthesia and postoperative epidural analgesia for 1 week and had preconditioning regular
with those of only general anesthesia and postoper- breathing exercises. All previous pulmonary medi-
ative systemic analgesia in COPD patients under- cation had been discontinued at least 1 week before
going open AAA surgical repair. Additionally, we hospital admission.

3. Vol. 26, No. 2, February 2012 Pulmonary function after AAA open repair: epidural vs intravenous analgesia 151
The study was approved by the institutional and data for drugs and material were obtained
ethics committee, and all patients had given from the hospital administration and from the
informed consent regarding the procedural risks hospital pharmacy. Postoperative PFTs were per-
and outcomes. formed on all patients during postoperative days 1
and 4. For each patient, postoperative pain was
assessed at rest and during movement. Pain scores
Anesthetic, Surgical, and Postoperative
were assessed during postoperative days 1, 2, and
Procedures
4 by using the visual analog scale rating from
For the standard preoperative evaluation (including 0 (no pain at all) to 10 (worst possible pain). Compli-
cardiac echo stress test, PFTs, bowel preparation, cations related to the epidurally administered
and clinical consultation with the anesthesiologist), opioids, including pruritus, nausea, vomiting, motor
all patients were admitted to the hospital 3-4 days block, and respiratory depression, were recorded.
before surgery. The afternoon before surgery, an Length of ICU and hospital stay and sequelae of
epidural catheter was inserted at L1-L2 or L2-L3 postoperative pulmonary morbidity, including atel-
level in group I patients. The evening before ectasis and pulmonary infections, were also
surgery, all patients received 1.5 mg of oral broma- recorded.
zepam for premedication. After entering the oper-
ating room, all patients received 2.5 mg of Statistical Analysis
intravenous midazolam. Induction of general anes-
thesia was achieved with 1 mg/kg intravenous remi- Results for continuous variables were expressed as
fentanyl, 2 mg/kg propofol, and 0.6 mg/kg mean and standard deviation (SD). Categoric vari-
rocuronium. Group I patients received 10-15 mL ables were presented as numbers. Continuous and
of levobupivacaine 0.125% and 100 mg of fentanyl categoric data were compared by the Student t test
via the epidural catheter. Maintenance of anesthesia and 1-way analysis of variance. Probability ( p)
in group I patients was achieved with a mixture of values less than 0.05 were considered statistically
sevoflurane, oxygen, and cisatracurium and a basal important.
infusion of epidural levobupivacaine 0.125% and
5 mg/mL fentanyl at a rate of 4-6 mL/hr. Mainte- RESULTS
nance of anesthesia in group II patients was
achieved with a mixture of sevoflurane, oxygen, The two groups exhibited no significant differences
remifentanyl, and cisatracurium. All patients were in terms of demographic data, patient characteris-
managed with the same standardized protocols aim- tics, perioperative variables, and length of postoper-
ing for early extubation immediately after the ative hospital stay, which are presented in Table I.
surgical procedure and were transferred to the ICU Transfusion requirements were comparable
for overnight hemodynamic monitoring. Sixteen between the two groups. However, patients of
patients were operated using a straight prosthesis; combined general and epidural anesthesia group
and 14, using a bifurcated knitted Dacron prosthesis. were administered additional fluid infusions and
During the first 5 postoperative days, group I vasopressors (phenlyephrine) to counterbalance
patients received epidural analgesia with a mixture peripheral vasodilation and arterial pressure drop
of levobupivacaine 0.125% and 5 mg/mL fentanyl due to epidural anesthesia and to maintain a stable
with a basal rate of 3-5 mL/hr, bolus doses of 3-5 hemodynamic profile (mean arterial pressure above
mL, and a lockout interval of 20 minutes. Postoper- 60 mm Hg or systolic blood pressure above 90 mm
ative analgesia in group II patients, during the same Hg) throughout the entire surgical procedure.
period, was achieved with intravenous patient- Preoperatively, values of FEV1 and FVC were not
controlled mode of application of 10 mg/mL fentanyl different between groups. During postoperative
with a basal rate of 1.5-2.5 mL/hr, bolus doses of days 1 and 4, all patients (both groups) demonstrated
1-2.5 mL, and a lockout interval of 6 minutes. After reductions in both parameters. However, these
postoperative day 5, all patients received oral anal- reductions were significantly less pronounced in
gesics as required. The same attending and the group I patients (combined general and epidural
same resident anesthesiologist were responsible for anesthesia) compared with group II patients (general
epidural catheter insertion, pain management, anesthesia only). Group I patients showed signifi-
epidural doses and complications, as well as catheter cantly increased postoperative PFT values compared
removal. The actual cost for staff and pharmacy with group II patients at all time points (postopera-
charges, as well as the cost for material and drugs, tive day 1: FEV1(%): 32.3 ± 4.4 vs. 27.1 ± 1.6, p ¼
was calculated. Data on cost per hour for the staff 0.007, FVC(%): 35.4 ± 8.5 vs. 28.3 ± 2.3, p ¼ 0.035;

4. 152 Panaretou et al. Annals of Vascular Surgery
Table I. Demographics, patient comorbidities, intraoperative variables, and length of hospital stay;
continuous variables are expressed as mean ± standard deviation (SD)
Variables Group I (n ¼ 16) Group II (n ¼ 14) p value
Age (years) 68.7 ± 5.9 70.0 ± 6.2 n/s
Sex (male/female) 16/0 14/0 n/s
Weight (kg) 79.3 ± 9.4 76.1 ± 6.3 n/s
Height (cm) 172.9 ± 5.3 173.1 ± 5.6 n/s
Hypertension 13/16 11/14 n/s
Smoking history 16/16 12/14 n/s
Diabetes mellitus 4/16 2/14 n/s
Hyperlipidemia 7/16 6/14 n/s
Previous MI 4/16 3/14 n/s
Coronary artery disease 3/16 4/14 n/s
Aortic cross-clamping duration (minutes) 65.7 ± 5.8 64.6 ± 7.9 n/s
Duration of surgery (minutes) 223.2 ± 20.8 238.9 ± 19.5 n/s
Perioperative blood transfusion (units) 2.8 ± 1.0 3.3 ± 0.7 n/s
Length of hospital stay (days) 7.1 ± 1.0 7.5 ± 1.1 n/s
n/s, not significant.
Table II. Pulmonary function test values as Table III. Postoperative pain assessed at rest and
percentage of predicted values before and after during activity by visual analog scale (VAS);
the surgical procedure; values are expressed as values are expressed as mean ± standard deviation
mean ± standard deviation
Group I Group II
Group I Group II Postoperative day (n ¼ 16) (n ¼ 14) p value
Variable (n ¼ 16) (n ¼ 14) p value
VAS at rest
FVC (%) Day 1 1.1 ± 0.9 2.6 ± 1.6 0.020
Preoperative 66.2 ± 12 65.7 ± 4.6 0.922 Day 2 0.7 ± 0.8 1.9 ± 1.1 0.021
Postoperative day 1 35.4 ± 8.5 28.3 ± 2.3 0.035 Day 4 0.5 ± 0.5 1.4 ± 1.1 0.036
Postoperative day 4 51.3 ± 8.3 43.0 ± 7.9 0.046 VAS on activity
FEV1 (%) Day 1 2.3 ± 0.8 4.0 ± 1.7 0.013
Preoperative 60.1 ± 10.4 61.3 ± 5.7 0.784 Day 2 1.6 ± 0.7 2.8 ± 1.2 0.019
Postoperative day 1 32.3 ± 4.4 27.1 ± 1.6 0.007 Day 4 0.8 ± 1.1 2.0 ± 1.1 0.036
Postoperative day 4 50.4 ± 6.8 41.9 ± 6.8 0.017
postoperative day 4: FEV1(%): 50.4 ± 6.8 vs. 41.9 ± In group I, complications related to epidural or
6.8, p ¼ 0.017, FVC(%): 51.3 ± 8.3 vs. 43.0 ± 7.9, intravenous analgesia included pruritus (2 patients)
p ¼ 0.046) (Table II). None of the patients in both and peripheral motor block (1 patient); and in group
groups developed toxic symptoms related to II, pruritus (1 patient), nausea (1 patient), and
levobupivacaine. persistent vomiting (1 patient). Regarding return
Group I patients (epidural analgesia) showed of bowel function, bowel movements were evident
significantly decreased postoperative pain at all from postoperative day 2 or 3 in both groups. All
time points either while being at rest ( p < 0.05) or patients were put on liquids on postoperative day
while doing some activity ( p < 0.05), compared 3. Of 16 patients from the epidural group, five
with group II patients (systemic analgesia). Addi- suffered from nausea and vomiting (after liquid
tionally, the differences in postoperative pain levels diet), delaying the start of regular diet from postop-
between the two groups were more pronounced erative day 5 to postoperative day 6. In the intrave-
during activity and less pronounced by postopera- nous analgesia group, liquid diet initiation on day 3
tive day 4. Table III presents postoperative pain did not result in nausea or vomiting in any patient,
levels at rest and during activity according to visual although one patient had nausea and one experi-
analog scale at days 1, 2, and 4 after the surgical enced vomiting unrelated to liquid or food
procedure. Epidural catheters were removed on consumption in this group. The actual mean time
postoperative day 5. required for the patient to be on regular diet was

5. Vol. 26, No. 2, February 2012 Pulmonary function after AAA open repair: epidural vs intravenous analgesia 153
Table IV. Postoperative pulmonary Table V. The estimation of cost in terms of cost
complications and length of ICU stay; prolonged for staff, pharmacy charges, and costs for drugs,
intubation defined as inability of extubation calculated for each patient and for a 4-day
immediately after the surgical procedure; treatment
hypoxemia defined as PaO2 <60 mm Hg
Group I Group II
Group I Group II Costs (V) (V)
Variable (n ¼ 16) (n ¼ 14) p value
Personnel cost for applying the 290 180
Prolonged intubation 0/10 1/14 n/s method
ICU stay >24 hours 1/16 1/14 n/s Personnel cost for intervention for 250 250
Atelectasis 4/16 4/14 n/s pain relief and pulmonary
Pulmonary infection 0/16 2/14 n/s function tests
Personnel cost for minor side 95 65
effects/technical problems/
changing treatment strategy
4.7 days for the epidural group compared with 3.5 Pharmacy charges and cost for 169 72
days for the intravenous analgesia group. material
In group I, all patients were transferred extubated Personnel cost for catheter removal 30 e
in the ICU. One patient in group II could not be Total postoperative care 824 567
extubated immediately after surgery and required
additional mechanical ventilatory support until
postoperative day 1, resulting in a 2-day stay in of AAAs have also demonstrated improvement in
the ICU. This patient, however, was not excluded respiratory status with the use of epidural anesthesia
from pain assessment and PFTs during postoperative in similar settings. However, these studies empha-
day 1. In group I, four patients developed atelectasis sized the benefits of epidural anesthesia without
with no evidence of infection. In group II, four general anesthesia or in combination with mini-
patients developed postoperative atelectasis, which mally invasive surgical approaches. Besides,
in two of them advanced to pulmonary infection although there was a significant benefit in terms of
(Table IV). postoperative pulmonary morbidity, improvement
Regarding the economic analysis, the most rele- of pulmonary function was not demonstrated with
vant medical costs were estimated: the cost of PFTs.14,15
human resources as well as pharmacy charges and In our study, we showed a benefit of postopera-
the cost of drugs and material (Table V). Epidural tive PFTs, (FVC and FEV1) on postoperative days 1
analgesia resulted in a cost of V824 for each patient and 4, in COPD patients operated under combined
for the 4-day care, compared with V567 for intrave- general and epidural anesthesia and postoperative
nous analgesia (50% increased cost). epidural analgesia compared with COPD patients
All patients had an uneventful surgical recovery, with general anesthesia and intravenous analgesia.
with no reoperations or postoperative blood transfu- In addition, the assessment of postoperative pain
sions. There was no in-hospital mortality. during rest and activity revealed reduced levels of
pain at all time points in patients who received
DISCUSSION epidural analgesia compared with those who
received systemic analgesia. The difference in pain
Decision of elective open AAA repair depends on the levels between the two groups during activity
estimate of the risks and benefits involved. The diffi- underscores the important contribution of epidural
culty in making a decision stems from the necessity analgesia in patient mobilization.
to determine whether a high-risk COPD patient Although the statistical differences lack power
would benefit from the open operation, when the because of the limited number of patients included
endovascular approach is not feasible. Previous in the study, the results parallel the documented
prospective studies have shown that epidural anes- effects of epidural anesthesia in larger studies on
thesia offers many benefits during major abdominal abdominal vascular operations. Major centers treat-
vascular surgery, including inhibition of the surgical ing AAA patients have already adopted, as a part of
stress response, fewer pulmonary complications, their clinical pathways, the strategy of administering
and better postoperative pain control, in comparison combined general and epidural anesthesia to their
with patient-controlled systemic analgesia.13,14 COPD patients,6,7 owing to previously known posi-
Additionally, studies on high-risk pulmonary tive effects of combined general and epidural anes-
compromised patients undergoing reconstruction thesia on the overall outcome. By reporting the

6. 154 Panaretou et al. Annals of Vascular Surgery
findings of postoperative lung function tests, our been estimated in our hospital to be V9,000-
study reconfirms the specific positive benefit of V12,500 (uncomplicated cases with 9-10-day
this clinical practice for COPDeAAA surgical length of stay and 1-2 days in the ICU). In general,
patients. However, postoperative increased PFT the cost of epidural analgesia has been evaluated
values did not altered the overall clinical outcome. to be up to two to three times the cost of intravenous
Postoperative atelectases were equal between analgesia, although the cost has been deemed
groups; however, pulmonary infections were reasonable in relation to the benefit of pain control.
evident only in two of the patients in group II. In our study, we showed, except for the clinical
This lack of superiority of clinical complications in benefit in pain management, a clearly improved
group I, compared with group II, is probably owing pulmonary function in a highly compromised
to the small number of patients included in the patient group. Improvement in pulmonary function
study. Unfortunately, the feasibility of a large decreases the possibility of pulmonary complica-
single-center study is questionable because endo- tions and the potential cost associated with their
vascular repair is the surgical treatment of choice treatment.
for these patients. However, the benefit of improved The use of epidural catheters for 4 days was
pulmonary function is mandatory, as major vascular a protocol decision, based on the possible risks and
surgery in COPD patients may be followed by pro- benefits and the experience expressed in previous
longed intubation or reintubation in the ICU. These studies.16,17 In a previous study on postoperative
possible complications are likely to be prevented by pulmonary complications, the authors reported
pulmonary function improvement. their results after 5 days of epidural analgesia in
Postoperative lung function after major abdom- patients who had undergone major abdominal
inal surgery can be impaired with marked reduc- surgery.18 Although most of the recent studies
tions in VC and FEV1 lasting up to 1 month follow a protocol of 3 days of postoperative pain
postoperatively. Perhaps, the most profound effect management, it was our decisiondbased on an
of major abdominal and thoracic surgery on pulmo- extensive personal experience with postoperative
nary function is due to diaphragmatic dysfunction, pulmonary complications after major abdominal
decreased chest wall compliance, and pain-limited vascular surgery19dto evaluate lung function
inspiration. Although factors other than pain have improvement after 1 and 4 days of treatment.
been implicated in the development of postopera- However, the analgesic methods used in this study
tive respiratory dysfunction, such as reflex inhibi- have been thoroughly evaluated and accepted for
tion of phrenic nerve on diaphragmatic activation their safety by numerous previous studies.13e15 Pro-
and residual effects of general anesthetics, it is longed duration of epidural analgesia for more than
widely assumed that when postoperative patients 5 days has been reported to be followed by increased
are relatively pain-free, their pulmonary function probability of complications, whereas shorter dura-
is improved as a result of enhanced chest expansion, tion has been inadequate for pain relief.17
better breathing pattern, increased cough, Complications in our study regarding the use of
decreased sputum retention, and cooperation with epidural or intravenous analgesia were mild and tran-
physical therapy. The improvement of postoperative sient. A slight prolongation of normal bowel function
lung function can be explained by a direct beneficial return was evident in the epidural group compared
effect of epidural analgesia on diaphragmatic with the intravenous group. However, major compli-
contractility and breathing pattern, as well as cations were absent in both groups. The improvement
a significant superiority of epidural analgesia on in lung function after 4 days of postoperative treat-
postoperative pain relief compared with a patient- ment with epidural analgesia overcomes the possi-
controlled mode of application of systemic bility of postoperative complications and outweighs
analgesia.13 the relatively low increase in cost.
The same attending and the same resident anes- Our study included open AAA repair only by
thesiologistdfrom the division of pain service- transperitoneal aneurysm exposure because of the
dwere responsible for epidural analgesia during team’s preference and for reasons of comparability
the four postoperative days. Estimated difference between groups. Other researchers have proposed
in financial cost resulted in an increase of 50% using a retroperitoneal approach for repairing
owing to use of epidural analgesia (cost: V824/ AAA, but that approach results in increased postop-
patient) instead of intravenous analgesia cost: erative pain and questionable reduction of postoper-
V567/patient). The actual difference of V257/ ative pulmonary morbidity.20
patient may be considered low compared with the Pulmonary disease has been shown to increase
mean total cost of open AAA repair, which has rupture risk of AAA at a given diameter.21,22

7. Vol. 26, No. 2, February 2012 Pulmonary function after AAA open repair: epidural vs intravenous analgesia 155
Difficulties arise in treatment of specific COPD aneurysmectomy in patients with chronic obstructive
patients, as some studies have shown increased pulmonary disease. J Vasc Surg 2003;37:594e9.
8. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and anal-
mortality and morbidity after AAA repair.23,24 The gesia. Their role in postoperative outcome. Anesthesiology
perceived increased risk of surgery in patients’ 1995;82:1474e506.
consideration may outweigh the increased risk of 9. Ballantyne JC, Carr DB, deFerranti S, et al. The comparative
aneurysm rupture. Ultimately, the risk of interven- effects of postoperative analgesic therapies on pulmonary
tion depends mainly on the cardiac and renal outcome: cumulative meta-analyses of randomized,
controlled trials. Anesth Analg 1998;86:598e612.
comorbidities; so, while making the final decision, 10. Benzon HT, Wong HY, Belavic AM Jr, et al. A randomized
one must consider other aspects apart from the double-blind comparison of epidural fentanyl infusion
COPD factor alone. versus patient-controlled analgesia with morphine for post-
Our current study and another previous report horacotomy pain. Anesth Analg 1993;76:316e22.
show a low mortality and morbidity in COPD 11. Safwat AM. Epidural anesthesia is a valuable adjunct to
general anesthesia for abdominal vascular surgery. J Cardi-
patients after open AAA repair.24 Although endo- othorac Anesth 1989;3:505e8.
vascular repair is the treatment of choice, COPD 12. Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the
patients can successfully undergo open AAA repair; diagnosis, management, and prevention of chronic obstruc-
however, careful attention to additional risk factors tive pulmonary disease: GOLD executive summary. Am J
is essential for overall risk modification. Epidural Respir Crit Care Med 2007;176:532e55.
13. Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoper-
anesthesia with postoperative epidural analgesia ative patient-controlled and continuous infusion epidural
decreases the immediate postoperative pulmonary analgesia versus intravenous patient-controlled analgesia
dysfunction compared with systemic analgesia, with opioids: a meta-analysis. Anesthesiology 2005;103:
and is justified to be routinely used in all COPD 1079e88.
patients operated for AAA. However, possible clin- 14. P€ pping DM, Elia N, Marret E, Remy C, Tramr MR. Protec-
o e
tive effects of epidural analgesia on pulmonary complications
ical benefit concerning better pulmonary outcome after abdominal and thoracic surgery: a meta-analysis. Arch
needs to be evaluated in larger prospective random- Surg 2008;143:990e9.
ized studies. 15. McGregor WE, Koler AJ, Labat GC, et al. Awake aortic
aneurysm repair in patients with severe pulmonary disease.
Am J Surg 1999;178:121e4.
16. Kindler CH, Seeberger MD, Staender SE. Epidural abscess
This study was funded by a grant from the National and complicating epidural anesthesia and analgesia: an analysis
Kapodistrian University of Athens, Medical School No. of the literature. Acta Anaesthesiol Scand 1998;42:614e20.
70/48112. 17. Sicard GA, Reilly JM, Rubin BG, et al. Transabdominal
versus retroperitoneal incision for abdominal aortic surgery:
report of a prospective randomized trial. J Vasc Surg
REFERENCES 1995;21:174e81.
18. Jayr C, Thomas H, Rey A, Farhat F, Lasser P, Bourgain JL.
1. Kroenke K, Lawrence VA, Theroux JF, Tuley MR, Postoperative pulmonary complications. Epidural analgesia
Hilsenbeck S. Postoperative complications after thoracic using bupivacaine and opiods versus parenteral opiods.
and major abdominal surgery in patients with and without Anesthesiology 1993;78:666e76.
obstructive lung disease. Chest 1993;104:1445e51. 19. Bastounis E, Filis K, Georgopoulos S, Bakoyannis C,
2. Van Laarhoven CJ, Borstlap AC, VanBerge-Hegwegouwen DP, Xeromeritis N, Papalambros E. Selective use of the intensive
Palmen FM, Verpalen MC, Schoemaker MC. Chronic obstruc- care unit after elective infrarenal abdominal aortic aneu-
tive pulmonary disease and abdominal aortic aneurysms. Eur J rysm repair. Int Angiol 2003;22:308e16.
Vasc Surg 1993;7:386e90. 20. Cronenwett JL, Murphy TF, Zelenock GB, et al. Actuarial
3. Bengston H, Bergvist D, Ekberg O, Janzon L. A population analysis of variables associated with rupture of small abdom-
based screening of abdominal aortic aneurysms. Eur J Vasc inal aortic aneurysms. Surgery 1985;37:724e32.
Surg 1991;7:53e7. 21. Powel JT, Brown LC. The natural history of abdominal aortic
4. Cronenwett JL, Murphy TF, Zelenok GB, et al. Actual anal- aneurysms and their risk of rupture. Acta Chir Belg
ysis of variables associated with rupture of small abdominal 2001;101:11e6.
aortic aneurysms. Surgery 1985;98:472e83. 22. Feinglass J, Cowper D, Dunlop D, et al. Late survival risk
5. Arko FR, Filis KA, Seidel SA, et al. How many patients with factors for abdominal aortic aneurysm repair: experience
infrarenal aneurysms are candidates for endovascular from fourteen Departments of Veterans Affairs hospitals.
repair? The Northern California experience. J Endovasc Surgery 1995;118:16e24.
Ther 2004;11:33e40. 23. Akersdijk GJ, Van der Graaf Y, Moll FL, et al. Complications
6. Compton CN, Dillavou ED, Sheehan MK, Rhee RY, of standards elective abdominal aortic aneurysm repair. Eur
Makaroun MS. Is abdominal aortic aneurysm repair appro- J Vasc Endovas Surg 1998;15:505e10.
priate in oxygen-dependent chronic obstructive pulmonary 24. Eskandari MK, Proctor MS, Henke PK, et al. Oxygen-
disease patients? J Vasc Surg 2005;42:650e3. depended chronic obstructive pulmonary disease does not
7. Upchurch GR, Proctor MC, Henke PK, et al. Predictors of prohibit aortic aneurysm repair. Am J Surg 1999;178:
severe morbidity and death after elective abdominal aortic 125e8.