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Vascular Surgery
General Principles
- Vascular surgery predominantly targets arteries affected by atherosclerosis, leading to ischemia or emboli.
- High mortality rates, with elective AAA surgery at 7% and emergency AAA surgery exceeding 50%.
- Uncontrolled cardiovascular disease significantly increases mortality rates.
- Procedures are often lengthy, necessitating blood transfusion, marked fluid shifts, and significant lung function impairment.
- Major vascular operations are now centralized in designated vascular centers.
- Patients typically are elderly with significant comorbidities: hypertension (66%), ischemic heart disease (angina, myocardial infarction), heart failure, diabetes mellitus, and chronic obstructive pulmonary disease (50% are current or former smokers).
- Many patients are on medications such as aspirin, β-blockers, diuretics, heart failure drugs, insulin, or oral hypoglycemics.
- Consider regional techniques cautiously in anticoagulated patients, although these techniques can reduce morbidity and mortality.
- Patients often have multiple previous surgeries; reviewing past anesthetic records is crucial.
- Approximately 30-40% of vascular surgeries occur out-of-hours.
- Measure non-invasive blood pressure (NIBP) in both arms due to possible arteriopathy; use the higher value clinically and place the arterial line on that side.
- Prophylactic antibiotic cover is necessary for all patients receiving synthetic vascular grafts.
- Establish a collaborative relationship with the vascular surgeon to anticipate untoward events (e.g., aortic clamping/unclamping, sudden massive blood loss).
Preoperative Assessment
- Evaluate the extent of any cardiorespiratory disease in relation to the planned surgical procedure and the postoperative period.
- Document the appropriateness of regional anesthesia.
- Include direct questions about exercise tolerance (e.g., walking distance, ability to climb stairs) and the ability to lie supine. Look for signs of cardiac failure.
- Investigations:
- Full blood count (FBC), urea and electrolytes (U&Es), electrocardiogram (ECG), chest X-ray (CXR), coagulation profile, and liver function tests (LFTs).
- Dynamic assessment of cardiac function for all elective aortic surgeries and patients with symptomatic/new cardiac disease.
- Cardiopulmonary exercise testing (CPET) is the ‘gold standard’ for all AAA patients (open or endovascular).
- Alternative tests include echocardiography, exercise ECG, stress echocardiography, radionuclide thallium scan, and multigated acquisition scan (MUGA). Refer patients with critical ischemic heart disease to cardiology for angiography and possible coronary revascularization before aortic surgery.
- Emergent vascular patients may need to undergo surgery before dynamic investigations can be performed.
- Perform lung function tests (including arterial blood gas analysis on room air) for patients with significant respiratory disease undergoing AAA repair.
Premedication
- Continue β-blockers and statins perioperatively.
- Anxiolytic premedication may be beneficial for major surgery.
Regional Anesthesia and Analgesia in Vascular Surgical Patients
- Regional anesthesia may be used alone for distal vascular surgery and is commonly employed for carotid surgery. However, the GALA trial of 3500 patients undergoing carotid endarterectomy (CEA) found no major outcome differences between general and regional anesthesia.
- Epidural analgesia is often used to supplement general anesthesia for AAA surgery.
- Advantages of regional techniques include:
- Improved patient monitoring (CEA)
- Reduced hospital stay and cost (CEA)
- Improved blood flow, reduced deep vein thrombosis (DVT), and fewer reoperations (peripheral revascularization)
- Post-operative pain relief (AAA, distal revascularization, amputation)
- Reduced pulmonary complications (AAA surgery)
- Pre-emptive analgesia for amputations, potentially reducing phantom limb pain
- Management of proximal hypertension during aortic cross-clamping
General Anesthesia Vs Regional Anesthesia
- The evidence is conflicting.
- Regional anesthesia may offer:
- Superior pain control
- Decreased endocrine response to surgery
- Reduced risk of cardiovascular, respiratory, gastrointestinal, and renal complications
- However, regional anesthesia does not appear to impact mortality rates significantly.
Anaesthesia for Varicose Veins
Intraoperative Management
Monitoring and Access
- Standard ASA monitors
- 5-lead EKG
- Peripheral IV x 1
Induction and Airway Management
- If General Anaesthesia is chosen:
- Standard induction
- Airway options: Laryngeal Mask Airway (LMA), Mask, or Endotracheal Tube (ETT)
- Neuromuscular blockade may not be required
- If Regional/Neuraxial Anaesthesia is chosen:
- Minimal to deep sedation is reasonable
- If Local + Monitored Anaesthesia Care (MAC):
- Deep sedation to general anaesthesia may be required
- Airway manipulation (e.g., oral airway or chin lift) may be necessary
Positioning
- Supine
Maintenance and Surgical Considerations
- Maintenance with volatile anesthetics or Total Intravenous Anaesthesia (TIVA)
- If regional/neuraxial techniques are used, minimal to deep sedation is reasonable
Emergence
- Postoperative Nausea and Vomiting (PONV) Prophylaxis
Postoperative Management
Disposition
- Post-Anesthesia Care Unit (PACU)
- Patients are usually discharged home
Pain Management
- Pain is generally minimal to mild
- Multimodal analgesia:
- PO/IV acetaminophen
- PO/IV NSAIDs
- PO/IV short-acting opioids (if required)
- Regional technique for pain management can be considered
Potential Complications
- Bleeding
- Ulcers
- Nerve injury
- Deep Vein Thrombosis (DVT)
- Infection
- Lymph fistula
Procedure Variants
Varicose Vein Stripping/Ablation
- Position: Supine
- Surgical time: 2-3 hours
- Estimated Blood Loss (EBL): 50-250 mL
- Postoperative Disposition: PACU, usually discharged home
- Pain Management: Minimal, multimodal
- Potential Complications: Bleeding and ulcers
Links
- Endovascular Abdominal Aortic Aneurysm Repair (EVAR)
- Peripheral Vascular Disease (PVD) and Risk Stratification
- Vascular physiology
- Upper and lower limb vascular surgery
- Vasculitis
Past Exam Questions
Coagulopathy in Major Vascular Surgery
a) Briefly outline the preoperative and intraoperative factors and pathophysiological processes that may contribute to the acute coagulopathy that develops during major vascular surgery. (7)
b) List three point-of-care tests that may help elucidate the cause of acute coagulopathy during major vascular surgery. (3)
References:
- (2016). Oxford handbook of anaesthesia, 4th end. European Journal of Anaesthesiology, 33(9), 700. https://doi.org/10.1097/eja.0000000000000522
Summaries:
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