202501071614

Status:

Tags: vascular

Pre-op optimisation of vascular patients

Lifestyle modification

• nutritional advice
  • obesity
  • malnutrition
• smoking cessation
  • minimum effective period 4-6 wks (ideally)
• regular exercise
  • Prehabilitation

Surgical waiting times:
Carotid surgery – current guidance recommends surgery within 2 weeks of first symptoms.
Surgery at more than 12 weeks beyond symptoms is generally no longer recommended.

Aortic surgery – both the NHS national aortic screening programme and Abdominal Aortic Aneurysm Quality Improvement Pathway recommend a target of 8 weeks from referral to surgery. This is to reduce risk of aortic rupture in the lead-up to surgery.

Possibility of non-operative Mx: MDT discussion

Cardiac:
Cardiac revascularization prior to vascular surgery is now rarely performed. Large prospective studies have demonstrated no outcome benefit in cardiac revascularization prior to vascular surgery in patients with chronic stable angina.

Resp:

DM:
HbA1c >8.5% & those w/ hypoglycaemia unawareness → refer to endocrine to optimise control
peri-op plan a/v
first on OT list to minimise fasting & allow resumption of normal diet & DM meds
if missing >1 meal → DKI infusion
poor control: may need overnight pre-op admission

Anaemia:
correct iron deficiency

Medications

β-blockers

Continue pre-existing β-blockers
Initiation of β-blockers should be considered in the following patient groups undergoing vascular surgery:

• coronary artery disease or the finding of cardiac ischaemia on preoperative testing
• high cardiac risk, as defined by the presence of ≥3 clinical risk factors
  If started, β-blockers should be started 4 weeks before surgery at a low initial dose and titrated to achieve a heart rate of 60–70 bpm.
  Bisoprolol is considered the agent of choice

Statin

All patients with established vascular disease should be commenced on statin therapy, ideally ≥2 weeks prior to surgery
Established statin therapy should be continued perioperatively

Antiplatelets

Aspirin should be continued perioperatively
Consider starting low-dose aspirin (75 mg) in individuals with established vascular disease not on treatment
Clopidogrel and prasugrel should be stopped for at least 7 days and ticagrelor 5 days prior to surgery to minimize bleeding risk.
However, following coronary interventions, dual antiplatelet therapy may need to be continued perioperatively.
A consensus decision between the cardiologist, surgeon and anaesthetist can be helpful

Anticoagulants

Thromboembolic and bleeding risk should be assessed prior to surgery
If there is a high risk of bleeding, warfarin should be stopped 5 days before surgery. INR should be ≤1.4 immediately prior to major surgery or if central neuraxial blockade is planned.
INR <2 is generally considered safe for infrainguinal arterial procedures under GA alone
Perioperative management of NOACs prior to central neuraxial blockade is dependent on the indication (prophylaxis or treatment) and the creatinine clearance
Patients at high risk of thromboembolic events should be treated with bridging therapy with UFH or low-molecular-weight heparin

Intervention

References

Risk Modification and Preoperative Optimization of Vascular Patients - A&ICM