The Safety Of High Dose Adenosine For Induction Of Temporary Asystole For Stent-Graft Deployment During Endovascular Abdominal Aortic Aneurysm Repair

RA Kahn MD, DM Moskowitz MD, LH Hollier MD, M Marin MD
Departments of Anesthesiology and Surgery
The Mount Sinai Medical Center
One Gustave L. Levy Place
New York, NY 10029

Kahn RA, Moskowitz DM, Hollier LH, Marin M: The Safety Of High Dose Adenosine For Induction Of Temporary Asystole For Stent-Graft Deployment During Endovascular Abdominal Aortic Aneurysm Repair. The Internet Journal of Anesthesiology 1999; Vol3N3: http://www.ispub.com/journals/IJA/Vol3N3/adenosine.htm; Published July 1, 1999; Last Updated July 1, 1999.

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Introduction
Methods
Conclusions
Results
References

Introduction (Back to Quick Links)

Endovascular stent-graft placement has recently become an alternative to conventional surgical treatment of abdominal aortic aneurysms (AAA).

Figure 1: Endovascular Aortic Repair

Table 1: Advantages of endovascular aortic repair

Figure 2: Mount Sinai Endovascular Graft

Figure 3: Mount Sinai Endovascular Graft

One technique used for the deployment of the endovascular aortic device employs large balloon angioplasty catheters to expand and secure the proximal stent portion of the endovascular graft to the underlying vessel wall. (Figure 4) These balloons have a large cross sectional area, predisposing them to distal aortic migration as a result of the forward aortic blood flow. This device malposition may result in either occlusion of major arterial branches or incomplete aneurysm exclusion. Many techniques have been advocated to prevent this distal migration. (Table 3) One of these techniques is the administration of high dose adenosine, which results in temporary high degree AV block ⁽²⁾. In this report, we present our experience with the use of high dose adenosine for induction of temporary asystole during endovascular aortic repair (EAR) in 100 patients.

Figure 4: Deployment of the endovascular aortic device

Table 2: Pharmacology of Adenosine

Table 3: Options for Prevention of Stent-Graft Migration During Deployment

Methods (Back to Quick Links)

Endovascular repair of AAA were carried out in accordance with investigator sponsored Investigational Device Evaluation protocol from the United States Food Federal Drug Administration, and approval of the Institutional Review Board.

Table 4: Anesthetic Preparation

After placement of either a temporary transvenous ventricular lead or an external transthoracic pacing electrodes, adenosine was administered in an escalating dose fashion in order to induce at least 10 seconds of asystole during proximal stent-graft deployment.

Table 5: Induction of Asystole

Results (Back to Quick Links)

The records of 100 patients undergoing EAR were reviewed. The dose range of adenosine administered was 12-90 mg with a median value of 24 mg. Two patients had transient episodes of myocardial ischemia (diagnosed by ST segment depression), which resolved within 30 seconds after return of the patient’s baseline rhythm. Two patients developed atrial fibrillation after adenosine administration, which responded to synchronized direct current cardioversion, and one patient developed a transient bundle branch block, which did not adversely effect hemodynamics. Four patients required temporary activation of their indwelling temporary transvenous pacemakers for prolonged bradycardia or AV block after adenosine. No patients developed bronchospasm, required treatment for worsening obstructive pulmonary disease, or received inotropic support that was not required prior to adenosine administration.

Table 6: Results of the Study

Conclusions (Back to Quick Links)

EAR is a viable alternative to conventional open surgical aortic reconstruction. The perioperative use of high dose adenosine to ensure precise stent-graft placement appears to be a safe method of inducing temporary asystole during endovascular aortic repair in this high risk surgical population.

Table 7: Conclusions of the Study

References (Back to Quick Links)

1) Kahn RA, Moskowitz DM, Manspeizer HA, et al.: Endovascular aortic reconstruction is associated with greater hemodynamic stability compared with open aortic reconstruction. Journal of Cardiothorac and Vascular Anesthesia 13: 42-46,1999. (Back to text)

2) Dorros G, Cohn JM: Adenosine-induced transient cardiac asystole enhances precise deployment of stent - grafts in the thoracic of abdominal aorta. J Endovasc Surg 1996; 3: 270-272. (Back to text)

3) Kahn R, Marin M, Hollier L, et al.: Induction of ventricular fibrillation to facilitate endovascular stent graft repair of thoracic aortic aneurysms. Anesthesiology 88: 534-536, 1998. (Back to text)