What are the preoperative evaluations and interventions for patients undergoing vascular surgery?

Preoperative Evaluation and Interventions for Vascular Surgery Patients

Mandatory Cardiovascular Risk Evaluation

All patients undergoing major vascular surgery must receive a preoperative cardiovascular risk evaluation, as vascular surgery carries the highest perioperative cardiac risk among noncardiac procedures. 1

Clinical Risk Stratification

• Use the Revised Lee Cardiac Risk Index to quantify cardiac risk based on: high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, renal failure, hypertension, and age >75 years 2
• Patients with ≥3 risk factors are considered high-risk and require additional evaluation 2
• Vascular surgery itself is classified as high-risk, automatically placing all patients in an elevated risk category 1

Preoperative Testing Algorithm

12-Lead Electrocardiogram

• Mandatory for all patients with ≥1 clinical risk factor undergoing vascular surgery 1
• Reasonable even for patients with no clinical risk factors undergoing vascular procedures 1
• Required for patients with known coronary artery disease, peripheral arterial disease, or cerebrovascular disease 1

Noninvasive Stress Testing

• Indicated for patients with ≥3 clinical risk factors AND poor functional capacity (<4 METs) if results will change management 1
• May be considered for patients with 1-2 clinical risk factors and poor functional capacity (<4 METs) if it will change management 1
• May be considered for patients with 1-2 clinical risk factors and good functional capacity (≥4 METs) 1
• Not recommended routinely for patients with 0-2 risk factors, as it delays surgery by up to 3 weeks without proven benefit 2
• Only recommended for patients with unstable angina or active arrhythmia 2

Left Ventricular Function Assessment

• Reasonable for patients with dyspnea of unknown origin 1
• Reasonable for patients with heart failure and worsening dyspnea or change in clinical status 1
• May be considered if no assessment within the past year in patients with previously documented LV dysfunction 1

Functional Capacity Assessment

• Patients with excellent functional capacity (>10 METs) can proceed to surgery without further cardiac testing 1
• Cardiopulmonary exercise testing may be considered for patients with unknown functional capacity 1

Preoperative Coronary Revascularization

Routine coronary revascularization is NOT recommended before vascular surgery exclusively to reduce perioperative cardiac events. 1

Indications for Preoperative Revascularization

• Significant left main coronary artery stenosis with stable angina 1
• Three-vessel disease with stable angina (greater benefit if LVEF <0.50) 1
• Two-vessel disease with significant proximal LAD stenosis and either LVEF <0.50 or demonstrable ischemia 1
• High-risk unstable angina or non-ST-elevation MI 1
• Acute ST-elevation MI 1

Timing of Surgery After PCI

• Delay surgery ≥14 days after balloon angioplasty 1
• Delay surgery ≥30 days after bare-metal stent placement 1
• Optimally delay surgery 365 days after drug-eluting stent implantation 1
• Elective surgery may be considered after 180 days post-DES if further complication risk is low 1

Perioperative Medical Therapy

Beta-Blocker Therapy

Beta-blockers should be given to patients undergoing vascular surgery who are at high cardiac risk (>1 clinical risk factor). 1

• Continue beta-blockers in all patients already taking them for angina, arrhythmias, hypertension, or other Class I indications 1
• Probably recommended for patients with documented coronary heart disease 1
• Probably recommended for patients with >1 clinical risk factor 1
• Uncertain benefit for patients with single clinical risk factor 1
• Uncertain benefit for patients with no clinical risk factors not currently on beta-blockers 1
• Start bisoprolol 2.5-5 mg daily 1 month before surgery, titrated to heart rate <70 bpm and systolic BP ≥120 mmHg 2
• Do not give to patients with absolute contraindications 1

Statin Therapy

Statin use is reasonable for all patients undergoing vascular surgery regardless of clinical risk factors. 1

• Start statins ideally 30 days before surgery using long-acting formulations (e.g., fluvastatin 80 mg daily) 2
• Statins sharply decrease MI, stroke, and death both perioperatively and long-term 2
• May be considered for patients with ≥1 clinical risk factor undergoing intermediate-risk procedures 1
• Target LDL <100 mg/dL per peripheral arterial disease guidelines 1

Alpha-2 Agonists

• May be considered for perioperative hypertension control in patients with known CAD or ≥1 clinical risk factor 1
• Do not give to patients with contraindications 1

Antiplatelet Therapy

• Continue aspirin perioperatively when possible 1
• Dual antiplatelet therapy required for appropriate duration after coronary stenting 1
• Consensus decision regarding continuation versus discontinuation should be made based on bleeding versus thrombotic risk 1

Intraoperative Management

Anesthetic Considerations

• Volatile anesthetic agents are beneficial for maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia 1
• Prophylactic intraoperative nitroglycerin has unclear benefit for high-risk patients, particularly those requiring nitrates for angina control 1

Monitoring and Temperature Management

• Preoperative intensive care monitoring with pulmonary artery catheter might be considered in highly selected unstable patients with multiple comorbidities, but is rarely required 1
• Maintain normothermia throughout the procedure except during periods requiring mild hypothermia for organ protection 1
• Emergency transesophageal echocardiography is reasonable for acute, persistent, life-threatening hemodynamic abnormalities 1

Glucose Control

• Reasonable to control blood glucose concentration perioperatively 1

Additional Risk Factor Optimization

• Control blood pressure to <140/90 mmHg 1
• Mandatory cigarette smoking cessation 1
• Optimize heart failure management before surgery 1
• Address significant valvular heart disease 3
• Manage arrhythmic burden 3

Common Pitfalls to Avoid

• Do not perform routine stress testing in patients with 0-2 risk factors, as it delays surgery without proven benefit 2
• Do not pursue coronary revascularization solely to reduce perioperative risk 1, 2
• Do not start high-dose beta-blockers immediately preoperatively without titration, as this increases stroke and death risk 2
• Do not proceed with elective surgery within 30 days of bare-metal stent or within 180 days of drug-eluting stent placement 1
• Exercise caution applying beta-blocker recommendations to patients with decompensated heart failure, nonischemic cardiomyopathy, or severe valvular disease without coronary disease 1