Thoracic and Vascular Anesthesia
Dr. George Nicolaou
Program Director and Fellowship Coordinator
The academic Thoracic and Vascular Anesthesia Program continues to thrive and grow at an exponential pace in the Department of Anesthesia and Perioperative Medicine at Western University. Located at Victoria Hospital, it is an extremely busy program covering all types of complex elective and emergency cases, with the exception of lung transplantation.
Vascular surgery operates six times a week and thoracic surgery five times a week. We have monthly multi-disciplinary and morbidity and mortality rounds with our surgical colleagues to assure quality control and to keep up on current events.
The majority of vascular and thoracic patients coming through our institution have multiple co- existing diseases including severe cardiorespiratory compromise. These patients have an extensive preoperative evaluation by anesthesia and/or internal medicine, cardiology and respirology. We have developed a multi-disciplinary perioperative high-risk clinic for optimization and follow up of these patients. The Thoracic and Vascular Surgical Programs have their own postoperative step-down monitored units with invasive monitoring capabilities.
The robotic (da Vinci robot) and video-assisted thoracic surgical (VATS) programs are well developed at our institution and currently account for 80% of cases, the remainder being open thoracotomies or investigative procedures. On average per year, we perform 300 major pulmonary resections and 80 esophagectomies. We have the largest experience with esophagectomies and VATS procedures in Canada. To enhance our clinical experience and improve our teaching program, we have developed an advanced VATS surgery and anesthesia workshop using a pig model. Here, consultants can enhance their skills in fiberoptic bronchoscopy and management of one lung ventilation. The pediatric thoracic anesthesia program is evolving with the recruitment of a pediatric thoracic surgeon. Pediatric thoracic procedures include investigative, video-assisted and open procedures. Alongside this is the adult and pediatric regional anesthesia and acute pain program, allowing for excellent perioperative pain management. The majority of our adult and pediatric patients receive thoracic epidurals or paravertebral blocks for postoperative pain management.
The Vascular Division of Surgery at Victoria Hospital continues to be a pioneer in endovascular stenting of abdominal and thoracic aneurysms and claims one of the largest series in North America. In April 2013, the construction of the hybrid vascular operating room was completed. This hybrid suite is equipped with numerous large, high-definition, flat-screen monitors for viewing images as well as the patient’s vital signs. It combines the newest computer generated technology and the newest radiologic imaging in a sterile operating room environment. This gives the surgeons the ability to perform traditional, open surgery and minimally invasive, endovascular procedures on the same patient, at the same time, in the same place. Patient benefits include the following:
- Shorter procedure times;
- Less radiation used during imaging;
- Reduced need for ICU care;
- Shorter hospital stays;
- Faster recovery.
Ruptured abdominal and thoracic aneurysms that have favourable anatomy are repaired by the endovascular route at our institution. The thoraco- abdominal aneurysm program is well developed and these aneurysms are now generally repaired using endovascular branched stents.
The thoraco-abdominal aneurysms that cannot be repaired by using endovascular stents are repaired utilizing partial left heart bypass. Recently, we have started repairing aortic arch aneurysms via the endovascular route. We use rapid ventricular pacing to optimize surgical conditions before stent deployment.
On average per year, we perform 150 open abdominal aneurysm repairs, 35 endovascular thoracic, 150 endovascular abdominal and 12 endovascular thoraco- abdominal aneurysm repairs.
Preliminary results of one of our studies have shown that spinal oximetry detects decreases in spinal cord blood flow early, allowing for the early initiation of preventive. We presented our results on spinal cord protection strategies at the 2012 International Forum of Cardiovascular Anesthesia in China.
Research Projects in Progress
- The influence of CPAP and PEEP (with a recruitment maneuver) on PaO2 during one lung ventilation, employing a lung protective ventilation strategy;
- Treatment modalities for spinal cord protection;
- Comparing Transcutaneous to Transdural Near-Infrared Spectroscopy for Detection of Regional Spinal Cord Ischemia in a porcine model;
- Biochemical markers of spinal cord ischemia in patients
- Undergoing thoracic aortic endovascular repair;
- Malignant Pleural Effusion Thoracoscopic Outpatient Pleurodesis. A feasibility trial.
Our Residency Program includes two four-week blocks of subspecialty training in vascular and thoracic anesthesia. Educational objectives are clearly outlined and monitored through daily assessments. Reading material is provided and residents are encouraged to partake in clinical research. At the beginning and the end of their rotations, the residents have an MCQ examination to assess improvement during their rotation. An oral examination is also administered at the end of the rotation.
Our Fellowship Program is well established with ongoing clinical research opportunities, in collaboration with our surgical colleagues. The program is one year in duration. Each week, the fellow will work two days independently in the operating room, one day in vascular and one day in thoracic with a consultant. The fifth day is for academic and research projects. The fellows are encouraged to attend x-ray rounds, thoracic/vascular rounds, fiberoptic bronchoscopy clinics and transesophageal rounds. Reading material is provided and fellows are encouraged to go to another centre for two weeks to broaden their experience. The Fellowship Program is extremely flexible, and is designed to accommodate the individual fellow’s needs.
The integration of simulation scenarios on thoracic and vascular anesthesia for fellows and residents has been very successful and rewarding. This environment allows for better preparation in this clinically diverse patient
population. We continue to develop in this frontier of enhanced learning.
Overall, the Thoracic and Vascular Program at Victoria Hospital is a very busy program with an incredible variety of interesting and complex cases. It is constantly evolving to keep up with medical and technological advances and to ensure that patients receive the most optimal perioperative care currently available. The program offers excellent opportunities for fellows to become proficient in adult and pediatric thoracic/vascular anesthesia, transesophageal echocardiography and point-of-care ultrasonography both in a clinical and research setting. It is designed to meet the individual’s needs, along with the best exposure to the available clinical caseload.