Preoperative Cardiac Evaluation and Management of the Patient Undergoing Major Vascular Surgery

About 313 million major surgical procedures are performed worldwide every year.1 Since the 1970s, vascular surgery has been identified as a subpopulation with disproportionately elevated risk.2,3 This risk persists today. For example, in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study of over 15,000 individuals undergoing major noncardiac surgery, vascular surgery was a predictor of 30-day mortality [adjusted hazard ratio (HR)=2.38].4 An analysis of about 123,500 cases in the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2010 revealed the absolute risk for death within 30 days after major vascular surgery to be 3%.5 Importantly, procedure-specific risks do vary considerably on the basis of the operative site, approach employed, and urgency of the procedure.6 An important reason for the elevated risk in vascular surgery patients is their burden of atherosclerotic disease. Many vascular surgical procedures address complications of peripheral arterial disease (PAD) or cerebrovascular disease (CVD). Atherosclerosis is the pathophysiological mechanism for both entities, as well as for coronary artery disease (CAD). Atherosclerosis involves plaques forming dense deposits in arterial walls and irreversibly expanding, subsequently leading to a narrowed vessel lumen and decreased compliance. Although atherosclerosis is not a regional process, it is defined in such terms; hence, the distinction between CAD, CVD, and PAD. Nonetheless, given their shared pathophysiology, there is a high association between CAD, CVD, and PAD.7 In the nonoperative setting, asymptomatic PAD is associated with a 3- to 4-fold increase in the risk of CAD and CVD.8 Further, the presence of PAD is a predictor of worse outcomes after both myocardial infarction (MI) and stroke.9,10 Thus, atherosclerosis in multiple organ systems is indicative of both disease breadth and severity. Because of the high risks of vascular surgery and the complex phenotype of patients undergoing these operations, it is imperative that anesthesiologists perform a thorough preoperative evaluation. The purpose of the preoperative assessment is to identify potential problems, ensure the patient is willing and able to tolerate the procedure with associated risks, mitigate perioperative risks, and facilitate appropriate postoperative monitoring. Given the influence of cardiovascular disease on outcomes in vascular surgery, it is important to identify individuals at risk to ensure appropriate management. Moreover, in individuals identified as being at very high risk, a frank discussion between the patient, surgeon, and anesthesiologist may be needed regarding the risks of the procedure, as well as possible alternatives to planned surgery. The goal of this chapter is to present an evidence-based approach to preoperative cardiac evaluation and management of patients undergoing major vascular surgery. Where possible, we focus on relevant current evidence and guidelines. The purpose is to present an approach to evaluate patients for common cardiac diseases and inform preoperative management. Thus, we will not discuss relatively uncommon cardiac diseases (eg, pulmonary hypertension, congenital heart disease), although these conditions are still important for perioperative care. Finally, we will assume sufficient time to complete a formal evaluation and permit management; however, we recognize this is often not the case. When discussing the urgency of cases, we use the definitions in the 2014 American College of Cardiology (ACC) and American Heart Association (AHA) perioperative guidelines. An emergency procedure is defined as threatening life or limb and requiring the patient to be in the operating room within <6 hours; an urgent procedure is defined as requiring an operation within 6 to 12 hours; a time-sensitive procedure is one that should be performed within 1 to 6 weeks, and an elective procedure allows time up to 1 year.11 Preoperative Evaluation Approach Preoperative evaluation is a key component of the preparation of patients before major surgery,12 especially for higher-risk patients and complex procedures.13 It enables identification of patients with elevated risk for complications, in turn facilitating appropriate individualized management. A thorough assessment can help identify comorbidities, assess disease severity, and determine the need for further testing. The purpose should be to inform perioperative management. For example, the evaluation can help alter medications, communicate risks accurately to patients, change intraoperative care, modify surgical procedures, or influence postoperative level of care. A systematic approach is best for capturing all relevant details. Thus, the classic approach should be adopted by first characterizing the presenting illness (with planned surgery, including indication), followed by studying the past medical history, conducting a focused physical examination, and reviewing previous investigations. Clinical History and Assessment Indications for Surgery: PAD and CVD The clinical assessment of the vascular surgery patient begins with the planned procedure and its indication. 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