Chapter 52
- Anesthesia for Vascular Surgery
- Edward J. Norris
The perioperative management of patients undergoing vascular surgery
is one of the most challenging and controversial areas in the field of anesthesiology.
Given the high incidence of coexisting disease, the hemodynamic and metabolic stress
associated with cross-clamping and unclamping, and the ischemic insults to the brain,
heart, kidneys, and spinal cord, it is not surprising that perioperative morbidity
is exceedingly high relative to that of other surgical procedures. The controversy
associated with routine preoperative screening for coronary artery disease (CAD)
has been fueled by issues related to cost containment and clinical efficiency. Ongoing
controversy continues over anesthetic technique and outcome because vascular procedures
often lend themselves to local, regional, general, or combined regional and general
anesthetics.
Much progress has been made in the management of vascular patients
in the past 3 decades. In the 1970s, it was recognized that vascular surgery, relative
to other surgeries, was a risk factor for perioperative cardiac morbidity. In the
1980s, the focus shifted to risk stratification in an effort to identify patients
who were at greatest risk for morbid outcomes. In the 1990s, there were numerous
clinical trials studying anesthetic technique, sympatholytic drugs, hemodynamic control,
and analgesic regimens that provided insight into the prevention, treatment, and
mechanisms of cardiac and other morbidity. More recently, the multidisciplinary
field of endovascular surgery has provided less invasive approaches or alternatives
to conventional vascular reconstruction.
The goal of this chapter is to review issues related to the perioperative
care of the vascular surgery patient and to address the underlying controversies.
For simplicity, each of five major categories of vascular procedures is discussed
separately: abdominal aortic surgery, thoracoabdominal aortic surgery, endovascular
aortic surgery, lower extremity vascular surgery, and carotid surgery. Additional
sections on preoperative and postoperative issues specific to each category of surgical
procedure are included. Specific recommendations regarding clinical care are selectively
provided and reflect the current practice at my institution.
