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Anesthesiology pp 625-633 | Cite as

Anesthesia for Lower Extremity Bypass

  • Jay Sanford
  • Brendan Atkinson
Chapter

Abstract

Due to the complexity of the procedures and the multiple complex comorbidities of the patients, vascular anesthesia is one of the more challenging sub-specialty fields within the practice of anesthesiology. Patients within this population are frequently elderly, suffer from multiple medical conditions and often present for surgery in emergent or urgent scenarios that afford little time for preoperative evaluation and medical optimization. Analysis of data from the National Surgical Quality Improvement Program (NSQIP) database, determined that vascular surgery carries an absolute risk of 30-day mortality of 3% [40]. The VISION study confirms these results demonstrating in 15,000 patients undergoing major non-cardiac surgery, vascular surgery is a predictor of 30-day mortality [39]. These reviews highlight that vascular surgery is inherently high risk, and as such carries a significant probability of perioperative and post-operative morbidity and mortality.

Vascular surgery encompasses a vast array of procedures spanning multiple vessels in the body, with a large portion of procedures involving the lower extremities. Lower extremity revascularization in particular, is indicated as a result of a variety of disease states, the most common being peripheral arterial disease (PAD). PAD is an increasing problem across the globe, affecting over 200 million people worldwide [38]. Due in large part to an overall increase in life expectancy, the number of patients expected to encounter vascular disease is on the rise. From 2000 to 2010, the global population saw an estimated 23.5% increase in the number of people suffering from PAD. While this number is skewed by increasing numbers of cases in lower-income countries, the rise in PAD in high-income countries such as the United States is not insignificant, with an estimated 13.1% in the same time period [38]. This chapter presents a systematic approach to preoperative, intraoperative, and post-operative management of patients undergoing lower extremity revascularization to aid anesthesiologists in providing optimal care for this medically diverse and exigent patient population.

Keywords

Lower extremity vascular surgery Pre-anesthesia evaluation of vascular surgery patients Peripheral arterial disease Coronary artery disease Lower extremity vascular anatomy Diabetes mellitus Perioperative medication management Regional vs. general anesthesia in vascular surgery 

References

  1. 1.
    Singh N, et al. The effects of the type of anesthesia on outcomes of lower extremity infra-inguinal bypass. J Vasc Surg. 2006;44(5):964–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Chung J, Bartelson B, et al. Wound healing and functional outcomes after infra-inguinal bypass with reversed saphenous vein for critical limb ischemia. J Vasc Surg. 2006;43:1183–90.CrossRefPubMedGoogle Scholar
  3. 3.
    Hur D, Kizilgul M, et al. Frequency of coronary artery disease in patients undergoing peripheral artery disease surgery. Am J Cardiol. 2012;110:736–40.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Mautner G, Mautner S, et al. Amounts of coronary arterial narrowing by atherosclerotic plaque at necropsy in patients with lower extremity amputation. Am J Cardiol. 1992;70:1143–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Hertzer N, Beven E, et al. Coronary artery disease in peripheral vascular patients. Ann Surg. 1984;199(2):223–33.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Ghadimi K, Thompson A. Update on perioperative care of the cardiac patient for non-cardiac surgery. Curr Opin Anesthesiol. 2015;28:342–8.CrossRefGoogle Scholar
  7. 7.
    Fleisher LA, et al. 2014 ACC/AHA guidelines on perioperative cardivascular evaluation and management of patients undergoing non-cardiac. J Am Coll Cardiol. 2014;64(22):e77–e137.CrossRefPubMedGoogle Scholar
  8. 8.
    Stepelfeldt WH, Yuan H, Dryden JK, Strehl KE, Cywinski JB, Ehrenfeld JM, Bromley P. The SLUScore: a novel method for detecting hazardous hypertension in adult patients undergoing noncardiac surgical procedures. Anesth Analg. 2017;124(4):1135–52.CrossRefGoogle Scholar
  9. 9.
    Fontes ML, Aronson S, et al. Pulse pressure and risk of adverse outcome in coronary bypass surgery. Anesth Analg. 2008;107(4):1122–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Asopa A, Jidge S, et al. Preoperative pulse pressure and major perioperative adverse cardiovascular outcomes after lower extremity vascular bypass surgery. Anesth Analg. 2012;114:1177–81.CrossRefPubMedGoogle Scholar
  11. 11.
    Hanada S, Kawakami H, Goto T, Morita S. Hypertension and anesthesia. Curr Opin Anesthesiol. 2006;19:315–9.CrossRefGoogle Scholar
  12. 12.
    Duggan E, et al. Perioperative hyperglycemia and management: an update. Anesthesiology. 2017;126(3):547–06.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119–31.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Joshi GP, Chung F, Vann MA, et al. Scoiety for ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg. 2010;111:1378–87.CrossRefPubMedGoogle Scholar
  15. 15.
    Dhartariya K, Levy N, Kivert A, Watson B, Cousins D, Flanagan D, Hilton L, Jairam C, Leyden K, Lipp A, Lobo D, Sinclair-Hammersley M, Rayman G, For the Joint British Diabetes Societies. NHS diabetes guideline for the perioperative management of the adult patient with diabetes. Diabetes UK position statements and care recommendations. Diabetes. 2012;29:420–33.CrossRefGoogle Scholar
  16. 16.
    Price JF, Mowbray PI, et al. Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease and coronary artery disease: Edinburgh artery study. Eur Heart J. 1999;20(5):344–53.CrossRefPubMedGoogle Scholar
  17. 17.
    Lu L, Mackay DF, Pell JP. Meta-analysis of the association between cigarette smoking and peripheral arterial disease. Heart. 2014;100:414–23.CrossRefPubMedGoogle Scholar
  18. 18.
    Willigendael EM, Teijink JA, et al. Influence of smoking on incidence and prevalence of peripheral arterial disease. J Vasc Surg. 2004;40(6):1158–65.CrossRefPubMedGoogle Scholar
  19. 19.
    Jonason T, Bergstrom R. Cessation of smoking in patients with intermittent claudication. Acta Med Scand. 1987;221:253–60.CrossRefPubMedGoogle Scholar
  20. 20.
    Willigendael EM, et al. Smoking and the patency of lower extremity bypass grafts: a meta-analysis. J Vasc Surg. 2005;42(1):67–74.CrossRefPubMedGoogle Scholar
  21. 21.
    Brabant SM, et al. The hemodynamic effects of anesthetic induction in vascular surgical patients chronically treated with angiotensin II receptor antagonists. Anesth Analg. 1999;88:138–1392.CrossRefGoogle Scholar
  22. 22.
    Comfere T, Sprung J, Kumar M, et al. Angiotensin system inhibitors in a general surgical population. Anesth Analg. 2005;100:636–44.CrossRefPubMedGoogle Scholar
  23. 23.
    Bertrand M, Godet G, Meersschaert K, et al. Should the angiotensin II antagonists be discontinued before surgery? Anesth Analg. 2001;92:26–30.CrossRefPubMedGoogle Scholar
  24. 24.
    Roshanov P, Rochwerg B, et al. Withholding versus continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before non-cardiac surgery. Anesthesiology. 2017;126:16–27.CrossRefPubMedGoogle Scholar
  25. 25.
    Bangalore S, Wetterslev J, et al. Perioperative B blockers in patients having non-cardiac surgery: a meta-analysis. Lancet. 2008;372:1962–76.CrossRefPubMedGoogle Scholar
  26. 26.
    Lindenauer P, Pekow P, et al. Perioperative beta-blocker therapy and mortality after major non-cardiac surgery. N Engl J Med. 2005;353:349–61.CrossRefPubMedGoogle Scholar
  27. 27.
    Bouri S, et al. Meta-analysis of secure randomized controlled trials of B-blockade to prevent perioperative death in non-cardiac surgery. Heart. 2014;100:456–64.CrossRefPubMedGoogle Scholar
  28. 28.
    Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high risk individuals: a randomized placebo-controlled trial. Lancet. 2002;360:7–22.CrossRefGoogle Scholar
  29. 29.
    Conte MS, et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg. 2015;61(3):2S–41S.CrossRefPubMedGoogle Scholar
  30. 30.
    Webster TD, et al. Perioperative management of dual anti-platelet therapy. Hosp Pract. 2016;44(5):237–41.CrossRefGoogle Scholar
  31. 31.
    Kil SW, Jung GS. Anatomical variations of the popliteal artery and its tibial branches: analysis of 1242 extremities. Cardiovasc Intervent Radiol. 2009;32(2):233–40.CrossRefPubMedGoogle Scholar
  32. 32.
    Ghanami RJ, et al. Anesthesia-based evaluation of outcomes of lower-extremity vascular bypass procedures. Ann Vasc Surg. 2013;27:199–207.CrossRefPubMedGoogle Scholar
  33. 33.
    Parker SD, Breslow MJ, et al. Catecholamine and cortisol responses to lower extremity revascularization: correlation with outcome variables. Crit Care Med. 1995;23:1954–61.CrossRefPubMedGoogle Scholar
  34. 34.
    Breslow MJ, Parker SD, et al. Determinants of catecholamine and cortisol responses to lower extremity revascularization. The PIRAT study group. Anesthesiology. 1993;79:1202–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Christopherson R, et al. Perioperative morbidity in patients randomized to epidural or general Anesthesia for lower extremity vascular surgery. Anesthesiology. 1993;79:422–34.CrossRefPubMedGoogle Scholar
  36. 36.
    Perler BA, et al. The influence of anesthetic method on infra-inguinal bypass graft patency: a closer look. Am Surg. 1995;61(9):784–9.PubMedGoogle Scholar
  37. 37.
    Lobo SM, et al. Clinical review: what are the best hemodynamic targets for non-cardiac surgical patients? Crit Care. 2013;17:210.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Fowkes G, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329–40.CrossRefGoogle Scholar
  39. 39.
    Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307:2295–304.CrossRefGoogle Scholar
  40. 40.
    Siracuse JJ, Meltzer EC, Gill HL, et al. Outcomes and risk factors of cardiac arrest after vascular surgery procedures. J Vasc Surg. 2015;61:197–202.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of AnesthesiologyEmory University School of Medicine, Emory University HospitalAtlantaUSA

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