function after open abdominal aortic posoperative pulmonary aneurysm repair in patients with chronic...

Clinical Research

1Departmen2Division

Surgery, HippAthens, Greece

3DepartmeUniversity of A

4First DepSchool, Univer

Postoperative Pulmonary Function AfterOpen Abdominal Aortic Aneurysm Repair inPatients With Chronic ObstructivePulmonary Disease: Epidural VersusIntravenous 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 chronicobstructive pulmonary disease (COPD) undergoing open surgery for abdominal aorticaneurysm.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 functiontests (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 thevisual analog scale. Data were recorded for PFTs, postoperative pain, length of hospital stay,length of ICU stay, and postoperative pulmonary morbidity, including atelectasis and pulmonaryinfections.Results: There was no in-hospital mortality. Hospital stay was similar between the twogroups (group I: 7.1 ± 1.0, group II: 7.5 ± 1.1). Group I patients showed significantlyincreased 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 ¼0.017, FVC(%): 51.3 ± 8.3 vs. 43.0 ± 7.9, p ¼ 0.046). However, postoperative clinicalpulmonary morbidity was not different between groups. Group I patients showed signifi-cantly reduced postoperative pain at all time points compared with group II patients. Thesedifferences were more pronounced during postoperative days 1 and 2, both at rest (visualanalog 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).

t of Anesthesiology,HippokrationHospital, Athens, Greece.

of Vascular Surgery, First Department of Propeudeticokration Hospital, Medical School, University of Athens,.

nt of Anesthesiology, Aretaieio Hospital, Medical School,thens, Athens, Greece.

artment of Cardiology, Hippokration Hospital, Medicalsity of Athens, Athens, Greece.

Correspondence to: Konstantinos Filis, MD, PhD, Division ofVascular Surgery, First Department of Propeudetic Surgery, Hippokra-tion Hospital, Medical School, University of Athens, 34B FaneromenisStreet, 15562 Athens, Greece; E-mail: [email protected]

Ann Vasc Surg 2012; 26: 149–155DOI: 10.1016/j.avsg.2011.04.009� Annals of Vascular Surgery Inc.Published online: October 24, 2011

149

mailto:[email protected]

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, andreduce postoperative pain as well, in COPD patients undergoing elective infrarenal abdominalaortic aneurysm repair.

INTRODUCTION

Although various developments and refinements in

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)

continues to be a high-risk procedure associated

with life-threatening complications and increased

perioperative morbidity.1 In addition, COPD has

been associated with an increased prevalence of

AAA2,3 and is an independent factor for AAA

rupture.4 Obviously, endovascular AAA repair has

been now established as the treatment of choice

for this high-risk group of patients. However, endo-

vascular repair is feasible in less than 60% of

patients5; therefore, a number of AAA patients

with COPD will still remain under medical observa-

tion, waiting to undergo open AAA repair until it

becomes feasible in their case. Recent studies have

shown that perioperative morbidity and mortality

as well as long-term survival of these patients justify

open AAA repair,6 although different clinical

predictors (mainly cardiac and renal disease) of

severe morbidity and an unfavorable outcome

exist.7

A vast amount of literature underscores the bene-

ficial effects of epidural anesthesia and analgesia in

improving pain management and enhancing post-

operative recovery in comparison with general

anesthesia alone.8e10 Epidural anesthesia and post-

operative epidural analgesia attenuate reductions in

respiratory parameters during the postoperative

period, as compared with systemic analgesia in

patients undergoing abdominal vascular proce-

dures.11 Although epidural anesthesia has been

the common practice for open AAA repair, this prac-

tice comes largely from experience in abdominal

and thoracic surgery. Thus, it has not been

adequately studied in COPD patients undergoing

open AAA repair in terms of postoperative respira-

tory function, as evidenced by alterations in pulmo-

nary function tests (PFTs).

The objective of this study was to compare respi-

ratory effects of combined general and epidural

anesthesia and postoperative epidural analgesia

with those of only general anesthesia and postoper-

ative systemic analgesia in COPD patients under-

going open AAA surgical repair. Additionally, we

opted to assess the effect on pain management and

postoperative pulmonary function in this high-risk

group of patients.

METHODS

Study Group

Among 110 patients electively operated for an

infrarenal AAA (max diameter> 55 mm), during

a 5-year period (2004-2009), we reviewed 30

patients with severe COPD. Operations were per-

formed by the standard transperitoneal exposure,

by the same vascular surgical and anesthesia

teams. None of these patients fulfilled criteria for

endovascular aneurysm repair (in 18 cases due to

short aortic neck, in 12 due to iliac access prob-

lems). We excluded emergency cases, patients

with severely impaired left ventricular systolic

function with ejection fraction <30%, patients

with a history of cerebrovascular accident or of

renal and hepatic insufficiency, and patients

allergic to levobupivacaine.

Pulmonary disease was diagnosed by clinical

history and PFTs. Smoking history was present in

all patients. PFTs, including forced vital capacity

(FVC) and forced expiratory volume in 1 second

(FEV1), were measured preoperatively in all

patients by using a portable spirometer unit (Spiro-

lab II, SDI Diagnostics, Rome, Italy). With a good

flow-volume loop, each measurement was per-

formed three times, and the best trial was recorded.

The diagnosis of moderate to severe COPD was

defined by the presence of one or more of the

following criteria: PaCO2 >45 mmHg, FEV1 <70%

of predicted value, and FEV1/FVC <0.7, as the

same limits have been used by a network of interna-

tional experts.12 Patients were assigned to receive

either combined general and epidural anesthesia

and epidural postoperative analgesia (group I, n ¼16), or general anesthesia alone with postoperative

patient-controlled intravenous systemic analgesia

(group II, n ¼ 14). Preoperatively, all patients

received bronchodilator treatment with salbutamol

for 1 week and had preconditioning regular

breathing exercises. All previous pulmonary medi-

cation had been discontinued at least 1 week before

hospital admission.

Vol. 26, No. 2, February 2012 Pulmonary function after AAA open repair: epidural vs intravenous analgesia 151

The study was approved by the institutional

ethics committee, and all patients had given

informed consent regarding the procedural risks

and outcomes.

Anesthetic, Surgical, and PostoperativeProcedures

For the standard preoperative evaluation (including

cardiac echo stress test, PFTs, bowel preparation,

and clinical consultation with the anesthesiologist),

all patients were admitted to the hospital 3-4 days

before surgery. The afternoon before surgery, an

epidural catheter was inserted at L1-L2 or L2-L3

level in group I patients. The evening before

surgery, all patients received 1.5 mg of oral broma-

zepam for premedication. After entering the oper-

ating room, all patients received 2.5 mg of

intravenous midazolam. Induction of general anes-

thesia was achieved with 1 mg/kg intravenous remi-

fentanyl, 2 mg/kg propofol, and 0.6 mg/kg

rocuronium. Group I patients received 10-15 mL

of levobupivacaine 0.125% and 100 mg of fentanyl

via the epidural catheter.Maintenance of anesthesia

in group I patients was achieved with a mixture of

sevoflurane, oxygen, and cisatracurium and a basal

infusion of epidural levobupivacaine 0.125% and

5 mg/mL fentanyl at a rate of 4-6 mL/hr. Mainte-

nance of anesthesia in group II patients was

achieved with a mixture of sevoflurane, oxygen,

remifentanyl, and cisatracurium. All patients were

managed with the same standardized protocols aim-

ing for early extubation immediately after the

surgical procedure and were transferred to the ICU

for overnight hemodynamic monitoring. Sixteen

patients were operated using a straight prosthesis;

and 14, using a bifurcated knitted Dacron prosthesis.

During the first 5 postoperative days, group I

patients received epidural analgesia with a mixture

of levobupivacaine 0.125% and 5 mg/mL fentanyl

with a basal rate of 3-5 mL/hr, bolus doses of 3-5

mL, and a lockout interval of 20 minutes. Postoper-

ative analgesia in group II patients, during the same

period, was achieved with intravenous patient-

controlled mode of application of 10 mg/mL fentanyl

with a basal rate of 1.5-2.5 mL/hr, bolus doses of

1-2.5 mL, and a lockout interval of 6 minutes. After

postoperative day 5, all patients received oral anal-

gesics as required. The same attending and the

same resident anesthesiologist were responsible for

epidural catheter insertion, pain management,

epidural doses and complications, as well as catheter

removal. The actual cost for staff and pharmacy

charges, as well as the cost for material and drugs,

was calculated. Data on cost per hour for the staff

and data for drugs and material were obtained

from the hospital administration and from the

hospital pharmacy. Postoperative PFTs were per-

formed on all patients during postoperative days 1

and 4. For each patient, postoperative pain was

assessed at rest and during movement. Pain scores

were assessed during postoperative days 1, 2, and

4 by using the visual analog scale rating from

0 (no pain at all) to 10 (worst possible pain). Compli-

cations related to the epidurally administered

opioids, including pruritus, nausea, vomiting, motor

block, and respiratory depression, were recorded.

Length of ICU and hospital stay and sequelae of

postoperative pulmonary morbidity, including atel-

ectasis and pulmonary infections, were also

recorded.

Statistical Analysis

Results for continuous variables were expressed as

mean and standard deviation (SD). Categoric vari-

ables were presented as numbers. Continuous and

categoric data were compared by the Student t test

and 1-way analysis of variance. Probability ( p)

values less than 0.05 were considered statistically

important.

RESULTS

The two groups exhibited no significant differences

in terms of demographic data, patient characteris-

tics, perioperative variables, and length of postoper-

ative hospital stay, which are presented in Table I.

Transfusion requirements were comparable

between the two groups. However, patients of

combined general and epidural anesthesia group

were administered additional fluid infusions and

vasopressors (phenlyephrine) to counterbalance

peripheral vasodilation and arterial pressure drop

due to epidural anesthesia and to maintain a stable

hemodynamic profile (mean arterial pressure above

60 mm Hg or systolic blood pressure above 90 mm

Hg) throughout the entire surgical procedure.

Preoperatively, values of FEV1 and FVC were not

different between groups. During postoperative

days 1 and 4, all patients (both groups) demonstrated

reductions in both parameters. However, these

reductions were significantly less pronounced in

group I patients (combined general and epidural

anesthesia) comparedwith group II patients (general

anesthesia only). Group I patients showed signifi-

cantly increased postoperative PFT values compared

with group II patients at all time points (postopera-

tive day 1: FEV1(%): 32.3 ± 4.4 vs. 27.1 ± 1.6, p ¼0.007, FVC(%): 35.4 ± 8.5 vs. 28.3 ± 2.3, p ¼ 0.035;

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

percentage of predicted values before and after

the surgical procedure; values are expressed as

mean ± standard deviation

VariableGroup I(n ¼ 16)

Group II(n ¼ 14) p value

FVC (%)

Preoperative 66.2 ± 12 65.7 ± 4.6 0.922

Postoperative day 1 35.4 ± 8.5 28.3 ± 2.3 0.035


FEV1 (%)

Preoperative 60.1 ± 10.4 61.3 ± 5.7 0.784



Table III. Postoperative pain assessed at rest and

during activity by visual analog scale (VAS);

values are expressed as mean ± standard deviation

Postoperative dayGroup I(n ¼ 16)


VAS at rest

Day 1 1.1 ± 0.9 2.6 ± 1.6 0.020

Day 2 0.7 ± 0.8 1.9 ± 1.1 0.021

Day 4 0.5 ± 0.5 1.4 ± 1.1 0.036

VAS on activity

Day 1 2.3 ± 0.8 4.0 ± 1.7 0.013

Day 2 1.6 ± 0.7 2.8 ± 1.2 0.019

Day 4 0.8 ± 1.1 2.0 ± 1.1 0.036


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) (Table II). None of the patients in both

groups developed toxic symptoms related to

levobupivacaine.

Group I patients (epidural analgesia) showed

significantly decreased postoperative pain at all

time points either while being at rest ( p < 0.05) or

while doing some activity ( p < 0.05), compared

with group II patients (systemic analgesia). Addi-

tionally, the differences in postoperative pain levels

between the two groups were more pronounced

during activity and less pronounced by postopera-

tive day 4. Table III presents postoperative pain

levels at rest and during activity according to visual

analog scale at days 1, 2, and 4 after the surgical

procedure. Epidural catheters were removed on

postoperative day 5.

In group I, complications related to epidural or

intravenous analgesia included pruritus (2 patients)

and peripheral motor block (1 patient); and in group

II, pruritus (1 patient), nausea (1 patient), and

persistent vomiting (1 patient). Regarding return

of bowel function, bowel movements were evident

from postoperative day 2 or 3 in both groups. All

patients were put on liquids on postoperative day

3. Of 16 patients from the epidural group, five

suffered from nausea and vomiting (after liquid

diet), delaying the start of regular diet from postop-

erative day 5 to postoperative day 6. In the intrave-

nous analgesia group, liquid diet initiation on day 3

did not result in nausea or vomiting in any patient,

although one patient had nausea and one experi-

enced vomiting unrelated to liquid or food

consumption in this group. The actual mean time

required for the patient to be on regular diet was

Table IV. Postoperative pulmonary

complications and length of ICU stay; prolonged

intubation defined as inability of extubation

immediately after the surgical procedure;

hypoxemia defined as PaO2 <60 mm Hg

VariableGroup I(n ¼ 16)


Prolonged intubation 0/10 1/14 n/s

ICU stay >24 hours 1/16 1/14 n/s

Atelectasis 4/16 4/14 n/s

Pulmonary infection 0/16 2/14 n/s

Table V. The estimation of cost in terms of cost

for staff, pharmacy charges, and costs for drugs,

calculated for each patient and for a 4-day

treatment

CostsGroup I(V)

Group II(V)

Personnel cost for applying the

method

290 180

Personnel cost for intervention for

pain relief and pulmonary

function tests

250 250

Personnel cost for minor side

effects/technical problems/

changing treatment strategy

95 65

Pharmacy charges and cost for

material

169 72

Personnel cost for catheter removal 30 eTotal postoperative care 824 567


4.7 days for the epidural group compared with 3.5

days for the intravenous analgesia group.

In group I, all patients were transferred extubated

in the ICU. One patient in group II could not be

extubated immediately after surgery and required

additional mechanical ventilatory support until

postoperative day 1, resulting in a 2-day stay in

the ICU. This patient, however, was not excluded

from pain assessment and PFTs during postoperative

day 1. In group I, four patients developed atelectasis

with no evidence of infection. In group II, four

patients developed postoperative atelectasis, which

in two of them advanced to pulmonary infection

(Table IV).

Regarding the economic analysis, the most rele-

vant medical costs were estimated: the cost of

human resources as well as pharmacy charges and

the cost of drugs and material (Table V). Epidural

analgesia resulted in a cost of V824 for each patient

for the 4-day care, compared with V567 for intrave-

nous analgesia (50% increased cost).

All patients had an uneventful surgical recovery,

with no reoperations or postoperative blood transfu-

sions. There was no in-hospital mortality.

DISCUSSION

Decision of elective openAAA repair depends on the

estimate of the risks and benefits involved. The diffi-

culty in making a decision stems from the necessity

to determine whether a high-risk COPD patient

would benefit from the open operation, when the

endovascular approach is not feasible. Previous

prospective studies have shown that epidural anes-

thesia offers many benefits during major abdominal

vascular surgery, including inhibition of the surgical

stress response, fewer pulmonary complications,

and better postoperative pain control, in comparison

with patient-controlled systemic analgesia.13,14

Additionally, studies on high-risk pulmonary

compromised patients undergoing reconstruction

of AAAs have also demonstrated improvement in

respiratory statuswith the use of epidural anesthesia

in similar settings. However, these studies empha-

sized the benefits of epidural anesthesia without

general anesthesia or in combination with mini-

mally invasive surgical approaches. Besides,

although there was a significant benefit in terms of

postoperative pulmonary morbidity, improvement

of pulmonary function was not demonstrated with

PFTs.14,15

In our study, we showed a benefit of postopera-

tive PFTs, (FVC and FEV1) on postoperative days 1

and 4, in COPD patients operated under combined

general and epidural anesthesia and postoperative

epidural analgesia compared with COPD patients

with general anesthesia and intravenous analgesia.

In addition, the assessment of postoperative pain

during rest and activity revealed reduced levels of

pain at all time points in patients who received

epidural analgesia compared with those who

received systemic analgesia. The difference in pain

levels between the two groups during activity

underscores the important contribution of epidural

analgesia in patient mobilization.

Although the statistical differences lack power

because of the limited number of patients included

in the study, the results parallel the documented

effects of epidural anesthesia in larger studies on

abdominal vascular operations. Major centers treat-

ing AAA patients have already adopted, as a part of

their clinical pathways, the strategy of administering

combined general and epidural anesthesia to their

COPD patients,6,7 owing to previously known posi-

tive effects of combined general and epidural anes-

thesia on the overall outcome. By reporting the


findings of postoperative lung function tests, our

study reconfirms the specific positive benefit of

this clinical practice for COPDeAAA surgical

patients. However, postoperative increased PFT

values did not altered the overall clinical outcome.

Postoperative atelectases were equal between

groups; however, pulmonary infections were

evident only in two of the patients in group II.

This lack of superiority of clinical complications in

group I, compared with group II, is probably owing

to the small number of patients included in the

study. Unfortunately, the feasibility of a large

single-center study is questionable because endo-

vascular repair is the surgical treatment of choice

for these patients. However, the benefit of improved

pulmonary function ismandatory, asmajor vascular

surgery in COPD patients may be followed by pro-

longed intubation or reintubation in the ICU. These

possible complications are likely to be prevented by

pulmonary function improvement.

Postoperative lung function after major abdom-

inal surgery can be impaired with marked reduc-

tions in VC and FEV1 lasting up to 1 month

postoperatively. Perhaps, the most profound effect

of major abdominal and thoracic surgery on pulmo-

nary function is due to diaphragmatic dysfunction,

decreased chest wall compliance, and pain-limited

inspiration. Although factors other than pain have

been implicated in the development of postopera-

tive respiratory dysfunction, such as reflex inhibi-

tion of phrenic nerve on diaphragmatic activation

and residual effects of general anesthetics, it is

widely assumed that when postoperative patients

are relatively pain-free, their pulmonary function

is improved as a result of enhanced chest expansion,

better breathing pattern, increased cough,

decreased sputum retention, and cooperation with

physical therapy. The improvement of postoperative

lung function can be explained by a direct beneficial

effect of epidural analgesia on diaphragmatic

contractility and breathing pattern, as well as

a significant superiority of epidural analgesia on

postoperative pain relief compared with a patient-

controlled mode of application of systemic

analgesia.13

The same attending and the same resident anes-

thesiologistdfrom the division of pain service-

dwere responsible for epidural analgesia during

the four postoperative days. Estimated difference

in financial cost resulted in an increase of 50%

owing to use of epidural analgesia (cost: V824/

patient) instead of intravenous analgesia cost:

V567/patient). The actual difference of V257/

patient may be considered low compared with the

mean total cost of open AAA repair, which has

been estimated in our hospital to be V9,000-

V12,500 (uncomplicated cases with 9-10-day

length of stay and 1-2 days in the ICU). In general,

the cost of epidural analgesia has been evaluated

to be up to two to three times the cost of intravenous

analgesia, although the cost has been deemed

reasonable in relation to the benefit of pain control.

In our study, we showed, except for the clinical

benefit in pain management, a clearly improved

pulmonary function in a highly compromised

patient group. Improvement in pulmonary function

decreases the possibility of pulmonary complica-

tions and the potential cost associated with their

treatment.

The use of epidural catheters for 4 days was

a protocol decision, based on the possible risks and

benefits and the experience expressed in previous

studies.16,17 In a previous study on postoperative

pulmonary complications, the authors reported

their results after 5 days of epidural analgesia in

patients who had undergone major abdominal

surgery.18 Although most of the recent studies

follow a protocol of 3 days of postoperative pain

management, it was our decisiondbased on an

extensive personal experience with postoperative

pulmonary complications after major abdominal

vascular surgery19dto evaluate lung function

improvement after 1 and 4 days of treatment.

However, the analgesic methods used in this study

have been thoroughly evaluated and accepted for

their safety by numerous previous studies.13e15 Pro-

longed duration of epidural analgesia for more than

5 days has been reported to be followed by increased

probability of complications, whereas shorter dura-

tion has been inadequate for pain relief.17

Complications in our study regarding the use of

epidural or intravenous analgesiaweremildand tran-

sient. A slight prolongation of normal bowel function

return was evident in the epidural group compared

with the intravenous group. However,major compli-

cationswereabsent inbothgroups. The improvement

in lung function after 4 days of postoperative treat-

ment with epidural analgesia overcomes the possi-

bility of postoperative complications and outweighs

the relatively low increase in cost.

Our study included open AAA repair only by

transperitoneal aneurysm exposure because of the

team’s preference and for reasons of comparability

between groups. Other researchers have proposed

using a retroperitoneal approach for repairing

AAA, but that approach results in increased postop-

erative pain and questionable reduction of postoper-

ative pulmonary morbidity.20

Pulmonary disease has been shown to increase

rupture risk of AAA at a given diameter.21,22


Difficulties arise in treatment of specific COPD

patients, as some studies have shown increased

mortality and morbidity after AAA repair.23,24 The

perceived increased risk of surgery in patients’

consideration may outweigh the increased risk of

aneurysm rupture. Ultimately, the risk of interven-

tion depends mainly on the cardiac and renal

comorbidities; so, while making the final decision,

one must consider other aspects apart from the

COPD factor alone.

Our current study and another previous report

show a low mortality and morbidity in COPD

patients after open AAA repair.24 Although endo-

vascular repair is the treatment of choice, COPD

patients can successfully undergo open AAA repair;

however, careful attention to additional risk factors

is essential for overall risk modification. Epidural

anesthesia with postoperative epidural analgesia

decreases the immediate postoperative pulmonary

dysfunction compared with systemic analgesia,

and is justified to be routinely used in all COPD

patients operated for AAA. However, possible clin-

ical benefit concerning better pulmonary outcome

needs to be evaluated in larger prospective random-

ized studies.

This study was funded by a grant from the National and

Kapodistrian University of Athens, Medical School No.

70/48112.

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