Preoperative evaluation and management of vascular surgery patients is important to minimize complications. It includes assessing cardiac, pulmonary, renal, and diabetic status through history, exams, labs, and testing. Patients found to be high-risk may require optimization like smoking cessation or glucose control prior to elective surgery. During surgery, prophylaxis against DVT is recommended according to patient risk factors. Postoperative care focuses on glycemic control and resuming medications appropriately.

1. Preoperative Evaluation and
Management
Dr Saleem Jahangir
Yashoda hospital
Hyderabad

2. • Preoperative assessment and management of vascular patients are importance
because
• These patients have multisystem involvement.
• They are at high risk for complications after surgery and
• Complications can be minimized and optimal choices can be made for the
timing of elective surgery.

3. GENERAL PREOPERATIVE RISK
ASSESSMENT
• Every patient undergoing elective vascular surgery should have a preoperative
assessment that includes
• History and physical examination
• Blood analysis, and
• Electrocardiogram (ECG).
• Patient-specific areas of concern should receive a more detailed evaluation.

4. • Serum electrolyte concentrations should be evaluated and corrected if
abnormalities exist.
• A baseline creatinine- as some vascular interventions may compromise renal
function.
• Serum glucose concentration measured.
• Coagulation profile- to identify coagulation abnormalities.
• Chest radiography

5. Cardiac Evaluation
• Cardiac history, physical examination, and baseline ECG.
• Advanced cardiac testing - for selected patients.
• Recommendations provided by The American College of Cardiology (ACC)
Foundation and the American Heart Association (AHA).

6. • Further cardiac testing is not generally recommended in
• Patients with adequate functional capacity (>4 mets).
• Patients who have undergone coronary revascularization within 5 years and
have normal findings on coronary angiography or cardiac stress testing within
2 years.
• No significant functional changes.

7. • Dipyridamole- thallium imaging or dipyridamole stress echocardiography is
indicated for
• Patients at intermediate or high cardiac risk
• Poor or unknown functional capacity (<4 METs).
• Unstable angina or an active arrhythmia.

8. • Coronary angiography is recommended
• If there are signs of active ischemia and the patient is symptomatic.
• The functional status of the patient is a good predictor of both the cardiac and
overall risk of the patient for surgery and hospitalization.

9. • Patients with cardiac implantable electronic devices (CIEDs) may require
reprogramming to prevent the transient inhibition of pacing or the inappropriate
triggering of shocks.
• External defibrillation equipment should be available in the operating room.

10. PREOPERATIVE MEDICAL VERSUS INTERVENTIONAL
THERAPY FOR CARDIAC DISEASE
• Perioperative use of beta blockers is standard of care for most patients with
cardiac disease undergoing vascular surgery.
• The POISE (PeriOperative Ischemic Evaluation) trial.
• There is reduction in primary cardiac events with perioperative beta-blockade
therapy
• This benefit is offset by an increased risk of stroke and total mortality.

11. • Recommendations for beta-blocker use is in patients
• Who have been on them chronically.
• With intermediate or high-risk myocardial ischemia.
• Having three or more revised cardiac risk index (RCRI) risk factors (e.g.,
Diabetes mellitus, heart failure, coronary artery disease, renal insufficiency,
cerebrovascular accident).
• Titrated to adjust for bradycardia and hypotension.

12. • Most other “home” medicines, including aspirin, statins, and antihypertensives,
should be continued.
• Statins should be initiated prior to surgery.
• Statins reduce the risk of adverse cardiovascular events through effects on
endothelial function, reduction in vascular inflammation, and stabilization of
atherosclerotic plaque.

13. • Current ACC/AHA guidelines support the use of DAPT following percutaneous
coronary intervention (PCI).
• If the risk of surgical bleeding is high, elective vascular procedures should be
postponed until DAPT can be safely withheld.
• Elective noncardiac surgery should be delayed 30 days after BMS implantation
and optimally 6 months after DES implantation.

14. • If noncardiac surgery is anticipated to be performed soon after stent placement, the
bare metal stent is preferred
• Patients on DAPT and surgical procedures that mandate the discontinuation of
P2Y12 inhibitor therapy,
• It is recommended that aspirin be continued if possible and
• P2Y12 platelet receptor inhibitor be restarted as soon as possible after surgery.

15. THE CORONARY ARTERY REVASCULARIZATION PROPHYLAXIS (CARP) TRIAL
• Coronary artery revascularization before elective major vascular surgery in stable
CAD patients
• Does not improve long-term cardiac outcomes or
• Reduce short-term postoperative outcomes.

16. • Preoperative coronary artery revascularization in vascular patients
• Increased risk for procedure related complications and
• Leads to delay in the intended vascular procedure.
• Recent CABG or PCI (<5 years) before vascular surgery
• No survival advantage over patients at high cardiac risk without previous
coronary interventions.

17. • Only the subset of patients with unprotected left main disease showed a benefit
from preoperative coronary artery revascularization.
• CABG has improved outcomes versus PCI.

18. Preoperative Management of Hypertension
• Elective surgery should generally be delayed if systolic blood pressure is greater
than 200 mm Hg or diastolic blood pressure is greater than 120 mm Hg.
• Pain can elevate blood pressure.
• Appropriate analgesia with nonsteroidal anti-inflammatory drugs or opioids
should be administered to alleviate pain.

19. • “home” antihypertensive medications should be continued.
• The incidence of intraoperative hypotension appears to be increased in patients
receiving ACEIs or ARBs on the day of surgery.
• Increased risk of all-cause death, stroke, and MI.

20. Pulmonary Evaluation
• History, physical examination and preoperative pulmonary evaluation.
• Pulmonary complications are reported in
• 1% to 2% of minor surgeries and up to
• 20% in upper abdominal or thoracic operations.

21. • Patient-related risk factors for postoperative pulmonary complications include
• Chronic obstructive pulmonary disease.
• Age older than 60 years.
• ASA class II or higher.
• Functionally dependent.
• Smoking.
• Forced expiratory volume (FEV1) <1 L.
• Congestive heart failure, and obesity.

22. • Patients with a BMI ≥ 40 kgm2
• 30% chance of developing atelectasis and/or pneumonia.
• All major surgeries have risk of pulmonary complications.
• History of smoking, exercise intolerance, unexplained dyspnea, or coughing
should be known prior to surgery.
• On physical examination, decreased breath sounds, wheezes, crackles, or a
prolonged expiratory phase should be noted.

23. • American College of Physicians recommends preoperative PFT only in patients
who have undiagnosed chronic obstructive pulmonary disease.
• Low serum albumin (<35 g/L) is an independent marker of increased risk for
postoperative pulmonary complications.

24. • Risk reduction strategies should be used in patients identified as at risk for
pulmonary complications.
• Smoking cessation,
• Respiratory physiotherapy,
• Respiratory muscle training,
• Optimization of nutritional status, and
• Postoperative lung expansion techniques when appropriate.

25. • Active smokers have a twofold increased risk for postoperative complications.
• Patients who have quit smoking for more than 6 months have a risk similar to
those who do not smoke.
• Smoking cessation,
• Improvs ciliary function and
• Decrease in sputum production.

26. • Strategies to improve the quit rate for smoking include
• Counselling,
• Nicotine replacement therapy,
• Bupropion, and
• Varenicline.
• Nicotine replacement therapy is available in several formulations
• Transdermal patch,
• Gum,
• Nasal spray,
• Inhaler, and
• Lozenge.

27. • Bupropion is an atypical antidepressant, and varenicline is a partial agonist of the
α4β2 nicotinic acetylcholine receptor.
• Second line agents are nortriptyline, a tricyclic antidepressant, and clonidine, an
antihypertensive drug.
• Varenicline has been shown to offer significant improvement in abstinence rates
over antidepressants.

28. • Optimization before surgery in patients with a history of bronchospasm and
chronic obstructive pulmonary disease
• Inhaled bronchodilators,
• β2 agonists, and
• Anticholinergics.
• Should begin at least 5 days before surgery.
• Systemic corticosteroids are recommended when the FEV1 is less than 80% of
predicted.

29. • Lung expansion techniques used to limit postoperative pulmonary complications
are
• Incentive spirometry,
• Chest physical therapy,
• Cough,
• Postural drainage,
• Ambulation, and
• Continuous positive airway pressure.

30. RENAL EVALUATION
• One-third of all vascular surgery patients suffer from stage III or higher chronic
kidney disease.
• Shared risk factors of diabetes, hypertension, atherosclerosis, obesity, alcohol,
nicotine abuse, and hypercholesterolemia.
• Kidney function must be carefully evaluated preoperatively.

31. • The preoperative evaluation should include an assessment for the presence of renal
failure symptoms such as
• Fatigue
• Dry skin
• Muscle cramps
• Decreased urine output
• Recurrent urinary tract infections
• Edema
• History of renal disease, and
• History of dialysis or transplantation.
• The examination should focus on signs of hyperkalemia, volume status, anemia,
and bleeding.

32. • In all patients
• Preoperative complete blood count to evaluate for anemia and
thrombocytopenia,
• Electrolyte and acid-base abnormalities.
• Baseline renal function
• Chest radiograph
• Signs of fluid overload.
• Examination of the vascular access site.
• Dialysis catheter- inspected for signs of infection functionality.
• Arteriovenous fistula or graft if present- assessed for functionality

33. • Hyperkalemia- corrected before surgical intervention.
• Treatment options include
• Polystyrene binding resins,
• Insulin in combination with intravenous dextrose,
• Calcium carbonate for cardiac stabilization,
• Intravenous bicarbonate, and
• Dialysis.
• Patients maintained with dialysis should undergo dialysis the day before surgery.

34. • Prolonged bleeding and frequent bruising can suggest a coagulation abnormality.
• Thrombocytopenia may result in an increased incidence of perioperative bleeding
and should be corrected before surgery.

35. • Anemia is usually present in patients with ESRD.
• Red blood cells can be transfused to correct the hematocrit before surgery.
• Unnecessary transfusion should be avoided.
• Elective surgery should be delayed until erythropoietin can be administered and
the hematocrit allowed to increase in response to the patient’s own production of
red blood cells.

36. • Contrast-induced nephropathy (CIN)
• Third most common cause of hospital-acquired acute renal injury
• Significant problem as more patients are receiving iodinated contrast media for
computed tomography, angiography, and endovascular therapies.
• Sodium bicarbonate and N-acetylcysteine can be used to prevent CIN
• There are insufficient data to recommend.

37. • Strategies to reduce the risk of CIN include
• Avoidance of iodinated contrast completely by using alternative imaging
techniques.
• Limit the volume of iodinated contrast agents and use only nonionic, low
osmolar agents
• Judicious periprocedural hydration with isotonic saline.

38. DIABETES
• The prevalence of undiagnosed diabetes in surgical patients is high.
• Complete diabetic history should be known.
• High glucose levels are associated with increased morbidity and mortality.
• Controlled before, during and after vascular surgery.
• Glucose control should be attained weeks before elective surgery.
• Hemoglobin A1c (HbA1c) is used to assess long-term glucose control.

39. • Preoperative HbA1c (within 180 days of surgery) of less than 7% is significantly
associated with a decrease in infectious complications.
• The American Diabetes Association, the Canadian Diabetes Association
recommendations on inpatient glycemic control.
• In the ICU, the glucose goal should be maintained between 140 and 180
mg/dL.
• For general medical and surgical patients
• Premeal glucose <140 mg/dL and
• Random blood glucose <180 mg/dL.

40. • Patients with type 2 diabetes treated by diet alone
• Abstain from oral intake overnight, and
• Hydration may be maintained with intravenous solutions.
• Hyperglycemia is treated with supplemental short-acting insulin.
• Oral agents are generally withheld the day of surgery, and hyperglycemia
corrected with insulin.
• Specific sliding scale insulin regimens are typically standardized on the basis of
hospital practices.

41. Adrenal Evaluation
• Patients who have been chronically treated with steroids are at risk for
perioperative adrenal crisis.
• Hypothalamic or pituitary dysfunction should be considered
• Tumor, previous brain irradiation, or sarcoidosis.
• Primary adrenal insufficiency may be present in
• Patients with tuberculosis,
• Acquired immunodeficiency syndrome, and
• Autoimmune endocrine syndromes.

42. • Intraoperative steroid coverage is not required in patients
• Taking less than 5 mg of prednisone (or its equivalent).
• Have been treated for less than 3 weeks, or
• Are taking less than 10 mg of prednisone (or its equivalent) every other day.
• They should continue to receive their regular daily dose of steroids.

43. • Patients taking greater than 20 mg per day of prednisone (or equivalent) should
receive supplemental perioperative steroid.
• Minor surgery
• Should receive 25 mg of hydrocortisone (or its equivalent) at the start of the
procedure.
• Their usual replacement dose after the procedure.

44. • Moderately complex surgery (lower limb revascularization)
• Should receive 50 to 75 mg of hydrocortisone on the day of surgery
• Tapered to the patient’s usual replacement dose over 1 to 2 days.
• For major surgery (cardiothoracic surgery of its equivalent)
• Should receive 100 to 150 mg of hydrocortisone on the day of surgery
• tapered to the patient’s usual dose over 2 to 3 days.

45. Deep Venous Thrombosis Prophylaxis
• The potential for (DVT) in surgical patients can be stratified by risk factors and
the type of operation.
• Patient’s
• Coagulation status
• Previous history of thrombotic events
• Current and previous exposure to antiplatelet and anticoagulant therapy should
be known.

46. • Possibility of procoagulant states should be known
• Antithrombin III deficiency.
• Protein c and s deficiency.
• Antiphospholipid syndrome.
• Disseminated intravascular coagulation.

47. DVT PROPHYLAXIS
PHARMACOLOGIC
PROPHYLAXIS
• UFH
• LMWH
• Fondaparinux
• Warfarin, and
• Direct thrombin or factor Xa
inhibitors.
MECHANICAL DEVICES
• Compression stockings
• Intermittent pneumatic
compression, and
• Venous foot pumps.

48. • Recommendations specific to vascular surgery are limited because of the lack of
large randomized trials.
• Recommendations for vascular surgery are pooled with recommendations for
patients undergoing general, urologic, gynecologic, bariatric, and plastic or
reconstructive surgeries.

49. Recommendations for Thromboprophylaxis in Various Risk Groups
RISK AND CONSEQUENCES OF MAJOR BLEEDING
COMPLICATIONS
Risk of Symptomatic VTE Average Risk (~1%)
High Risk (~2%) or Severe
Consequences
Very low (<0.5%) No specific prophylaxis
Low (~1.5%) Mechanical prophylaxis with IPC
Moderate (~3.0%)
LDUH, LMWH, or mechanical
prophylaxis, preferably with IPC
Mechanical prophylaxis, preferably
with IPC
High (~6.0%)
LDUH or LWMH plus mechanical
prophylaxis with ES or IPC
Mechanical prophylaxis, preferably
with IPC, until risk of bleeding
diminishes and pharmacologic
prophylaxis can be added
High-risk cancer surgery
LDUH or LMWH plus mechanical
prophylaxis with ES or IPC and
extended- duration prophylaxis with
LMWH postdischarge
Mechanical prophylaxis, preferably
with IPC, until risk of bleeding
diminishes and pharmacologic
prophylaxis can be added
High risk, LDUH and LMWH contraindicated or not available
Fondaparinux or low-dose aspirin (160
mg); mechanical prophylaxis,
preferably with IPC; or both
Mechanical prophylaxis, preferably
with IPC, until risk of bleeding
diminishes and pharmacologic
prophylaxis can be added

50. • Current recommendations from the american college of chest physicians in
patients with a history of HIT
• Non heparin anticoagulants, such as bivalirudin, lepirudin, or argatroban over
heparin.
• In patients with a history of HIT but without heparin antibodies, heparin
anticoagulants may be used

51. • Bridging anticoagulation with therapeutic doses of LMWH is recommended for
perioperative management of anticoagulation in high-risk patients
• High-risk patients include
• Mitral valve prosthesis,
• Any caged or tilting disc aortic prosthesis,
• Recent (within 6 months) stroke or TIA.
• Patients with a recent (within 3 months) history of VTE.
• Patients with atrial fibrillation with a recent (within 3 months) stroke or TIA,
or have a history of rheumatic valvular heart disease.

52. • Current recommendations
• Patients should be assessed at least 7 days prior to surgery,
• Discontinuation of warfarin 5 days prior to surgery
• undergo INR testing on the day before surgery.
• That LMWH should be started 3 days prior to surgery and stopped the day of
surgery.
• Bridging is resumed 12 to 24 hours after surgery depending on the risk of
bleeding.

53. INFECTION
• Patients with infection in the preoperative period have increased risk for surgical
site infection.
• Common sources of infection include
• Urinary tract
• Pulmonary system
• Ischemic extremity
• Any prosthetic material.

54. • History and Examination should be performed to elicit signs/symptoms of
infection
• Recent fever.
• Cough.
• Sputum production.
• Urinary symptoms.
• Tenderness or erythema over a graft site, or
• Purulence from an open wound or ischemic extremity.

55. • If infection is identified, elective surgery should be delayed until optimization.
• Choice of antibiotics should be tailored to sensitivities identified
• In the absence of infection- perioperative prophylactic antibiotic administration is
recommended
• Antibiotics should be administered within 1 hour before incision and should be
discontinued within 24 hours postoperatively.

56. PREOPERATIVE ANEMIA
• Low hematocrit levels increase the postoperative risk for death and cardiac events
in elderly patients.
• Anemic patients should be evaluated to determine whether transfusion is likely to
be of benefit.
• Patient’s cardiac status may influence the decision to transfuse.
• Current guidelines recommend adhering to a restrictive transfusion strategy when
possible.

57. • In adult and pediatric intensive care unit patients
• Transfusion should be considered at hemoglobin of 7 g/dL or less.
• In postoperative surgical patients
• Transfusion should be considered at a hemoglobin of 8 g/dL or less or
• Symptoms including chest pain, orthostatic hypotension, and tachycardia
unresponsive to fluid resuscitation.

58. • Transfusion should also be considered in
• Symptomatic anemia
• Actively bleeding
• If anticipated blood loss from surgery will result in the hemoglobin level’s
falling below the transfusion thresholds.
• For elective surgery, autologous transfusion or administration of erythropoietin
should be considered to boost the patient’s red blood cell volume.

59. NUTRITION
• Preoperative malnutrition contributes to an increased risk for postoperative
complications,
• Impaired wound healing and infection.
• Pulmonary complications.
• Longer hospital stay.
• Higher health cost, and
• Overall increased morbidity and mortality.

60. • Lower preoperative nutritional indices are associated with more severe systemic
inflammatory responses after major vascular surgery.
• Serum albumin is the standard laboratory assessment of nutritional status.
• Hypoalbuminemia (<3.5 g/dL) is an independent predictor of major adverse
events and death after major open vascular surgery.
• Similar relationship is not observed for endovascular procedures.

61. • Nutritional assessment should be performed for all vascular surgical patients.
• History evaluating changes in weight, appetite and functional status
• Symptoms of nausea, vomiting, dysphagia, constipation, diarrhoea, and related
gastrointestinal complaints should be assessed.
• Weight loss of more than 5% in 1 month or 10% in 6 months can signify an
increased risk for postoperative complications.

62. • Physical examination should focus on
• Body habitus
• Edema, pallor, decubitus ulcers,
• Petechiae, ecchymoses, poor skin turgor,
• Fissured tongue, inflamed gums, ulceration of the oral mucosa,
• Brittle hair, and nail abnormalities.

63. • Serum albumin is the most appropriate laboratory test to assess nutritional status.
• Albumin is the most abundant plasma protein and has a long half-life (18 to 21
days).
• Marker of chronic protein status and a better evaluation of nutritional status than
anthropometric measurements.
• Serum prealbumin and transferrin levels have a shorter half-life and are more
sensitive to the short-term response to nutritional support.

64. • Preoperative nutritional support can lower postoperative complication rates
particularly in those with severe malnutrition (albumin <2.1 g/dL).
• It is recommended that nutritional support be provided for 10 to 14 days before
major surgery.
• Immune enhancing nutritional supplementation can significantly reduce
postoperative complications.
• Immune-enhancing formulas intend to bolster function of the immune system
including arginine, glutamine, and ω-3 polyunsaturated long-chain fatty acids.

65. ETHICAL AND LEGAL CONCERNS
• Both the physician and patient must consider it as part of the decision to proceed
with surgery.
• The preoperative setting is ideal for both the patient and the physician to come to a
mutual understanding about the expectations of the physician-patient relationship
• The treatment decided on to minimize the chance that legal action will be initiated.

66. • Patient confidentiality is important to address the privacy and release of health
information.
• Physicians have a duty to maintain confidentiality with their patients.
• They may not disclose any medical information discovered in connection with the
treatment of a patient.

67. • Information contained in a patient’s medical record may be released to third
parties only if the patient provides consent.
• Breaches in confidentiality can lead to mistrust, lawsuits, or disciplinary action.
• Exceptions can be made if patients threaten bodily harm to themselves or to
others.

68. • Informed consent must be obtained from all patients before surgical intervention
• To provide consent, the patient must have an understanding of
• The diagnosis
• The purpose of a proposed procedure
• The risks and benefits associated with the procedure
• The alternative treatments, and
• The risks and benefits of not undergoing a procedure.

69. • If the patient does not have decision making capacity, a family member or
someone with power of attorney will need to be designated to make decisions on
behalf of the patient.
• Physicians should make themselves familiar with state laws regarding
confidentiality, reporting of abuse, and informed consent.

70. THANKYOU