Role of Epidural Anaesthesia in Elective Open Abdominal Aortic Aneurysm Repair: Secondary Analysis of a Randomised Trial

Abstract

OBJECTIVE: Using peri-operative epidural anaesthesia (PEA) during elective open abdominal aortic aneurysm (AAA) repair is debated by surgeons and anaesthetists. This study aimed to evaluate the clinical benefits and risks of PEA in patients undergoing elective open AAA repair. METHODS: This exploratory post hoc analysis of the ACTION-1 trial (NCT04061798), a multicentre, international, single blinded, randomised controlled trial designed to compare heparinisation strategies during elective open AAA repair, assessed outcomes by comparing patients receiving PEA with those managed with a local pain protocol. Primary outcomes included 30 day adverse events and health related quality of life (HRQoL), post-operative pain, and mobility scores one week after surgery assessed using the EQ-5D-5L questionnaire. The secondary outcome was intra-operative heparin dosage. RESULTS: The study included 294 patients, with 189 (64.3%) receiving PEA. Bleeding complications were lower in the PEA group (31.7%; n = 60) compared with the control group (48.6%; n = 51; p = .006). Death, pneumonia, length of admission, and other 30 day complications were similar between the groups. No epidural haematomas were reported. Post-operative pain scores were comparable across the first four EQ-5D-5L levels. However, no patient in the PEA group reported extreme pain or discomfort one week post-operatively compared with 3.8% (n = 4) in the control group (p = .014). Mobility was better in the PEA group: 44.9% reported no mobility issues compared with 30% (n = 28) in the control group (p = .019), while severe mobility problems were also less frequent in the PEA group (5.1% vs. 16%; p = .006). HRQoL was statistically significantly better in the PEA group one week (0.73 vs. 0.68; p = .007) and four weeks (0.81 vs. 0.76, p = .007) after surgery. CONCLUSION: PEA was found to be associated with fewer bleeding complications, reduced extreme pain, better mobility, and improved HRQoL one week post-operatively.