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Anaesthesiology
Anesthesia for Vascular and Endovascular Surgery
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
10 sections · 198 slides
Overview
- Scope of this topic
- Burden of atherosclerotic disease and surgical volume
- Falling mortality and reading the coronary burden data
Vascular disease
- Definition and proposed mechanisms of atherosclerosis
- Two stages of atherosclerosis development
- Endothelial injury and formation of the plaque core
- Fatty streak and the inflammatory mediators that follow
- End-organ consequences of plaque location
- The vulnerable plaque model and its limits
- Cardiovascular events by coronary disease severity and extent
- Risk factors for atherosclerotic disease
- Disease overlap between vascular beds
- Overlap of atherosclerotic disease by vascular bed
- Coronary disease prevalence found by routine angiography
- Coronary artery disease severity in vascular surgery patients undergoing coronary angiography
- Predicting coronary severity and its prevalence in peripheral disease
Medical optimisation before vascular surgery
- Cardiac risk and general optimisation measures
- Rationale and trial evidence for perioperative beta-blockade
- ST segment change with heart rate during an ischaemic episode
- Supply and demand in demand ischaemia
- Systematic review and guidance on beta-blockade
- Beta-blockade evidence specific to vascular surgery
- Trends in beta-blockade initiation before surgery, 2003 to 2012
- Choice of beta-blocking agent
- Alpha-2 adrenergic agonists
- RAS blockers and statin recommendations
- Perioperative risks and guidance for RAS blockers
- Statins and the risk of stopping them
- Antiplatelet agents before vascular surgery
- Type I versus type II perioperative myocardial infarction
- Guideline position on perioperative antiplatelet therapy
- Oral hypoglycaemic agents before surgery
- Intensive versus moderate glucose control
- Anaemia and transfusion practice
- Preoperative coronary revascularisation and the Monaco trial
- Survival with routine versus selective coronary angiography before vascular surgery
- The CARP trial and its subgroups
- Why CARP and Monaco disagree
- Timing after infarction and the weight of perioperative injury
- Timing of surgery after coronary stenting
- Post-stent timing at a glance
Preoperative anaesthesia evaluation
- History and examination before vascular surgery
- Baseline tests, biomarkers and echocardiography
- Survival after vascular surgery stratified by postoperative myocardial ischaemia
- Over-testing and step one of the algorithm
- Stepwise algorithm for cardiovascular evaluation before noncardiac surgery
- Steps two and three: active disease and risk estimation
- Independent predictors of cardiac events in vascular patients
- Step four: functional capacity and when to test
- The four-step preoperative pathway
Cerebrovascular disease and carotid endarterectomy
- Burden of stroke and trends in mortality
- Carotid disease as a cause of stroke, and its symptoms
- Transient ischaemic attack and reinterpreting the landmark trials
- Endarterectomy trials in symptomatic and asymptomatic disease
- Benefit of surgery by degree of stenosis
- Timing of endarterectomy after a symptomatic event
- Cardiac evaluation and combined carotid-coronary disease
- Cross-clamping and the circle of Willis
- Intact and hypoplastic circle of Willis
- Limits of collateral flow and the shunting debate
- Risks and limits of carotid shunting
- Categories of neurophysiological monitoring
- Purpose of monitoring and cerebral blood flow thresholds
- Electroencephalogram changes with falling cerebral blood flow
- EEG appearance of ischaemia and its limitations
- EEG confounders and somatosensory evoked potentials
- SSEP limitations and motor evoked potentials
- Transcranial Doppler monitoring
- Carotid stump pressure
- Near-infrared spectroscopy
- Preparation and the case for regional anaesthesia
- Cervical plexus block and patient suitability
- Advantages of general anaesthesia for endarterectomy
- Stroke or death and death after endarterectomy under general versus local anaesthesia
- The GALA trial and choosing a technique
- Airway and induction for carotid endarterectomy
- Opioids, relaxants and maintenance agents
- Recovery profile, cost and agent selection
- Carbon dioxide management during endarterectomy
- Hypothermia for cerebral protection
- Extubation and the new postoperative deficit
- Perioperative stroke and cerebral hyperperfusion syndrome
- Haemodynamic lability and infarction after endarterectomy
- Fluid management and working up postoperative hypertension
- Respiratory insufficiency and carotid body injury
- Respiratory precautions and wound haematoma
- Airway management of a neck haematoma, and the occlusion table
Aortic reconstruction
- Definition and classification of aortic aneurysm
- Aneurysm pathophysiology and rupture risk by size
- Cumulative incidence of aneurysm rupture by diameter at diagnosis
- Thresholds for elective aneurysm repair
- Aortic dissection and volume redistribution with clamping
- Classification and lethal mechanisms of dissection
- Haemodynamic response to aortic cross-clamping
- Systemic haemodynamic response to aortic cross-clamping
- Effect of level of aortic occlusion on cardiovascular variables (% change)
- Blood volume redistribution after aortic cross-clamp placement
- Supraceliac clamping and choosing an endovascular anaesthetic
- Myocardial consequences of cross-clamping
- Haemodynamic preparation for cross-clamping
- The unclamping events and their management
- Physiology of aortic cross-clamp release
- Haemodynamic response to aortic cross-clamp release
- Gradual release and surgical communication
- Renal failure after aortic cross-clamping
- Renal effects of infrarenal clamping
- Pharmacological renal protection strategies
- Blood supply of the spinal cord
- Vascular supply to the spinal cord
- Risk factors for spinal cord ischaemia
- Preventing cord ischaemia and the case for CSF drainage
- Practice of cerebrospinal fluid drainage
- Transabdominal versus retroperitoneal approach
- Epidural catheter and heparin timing
- Induction and monitoring for open aortic repair
- Choice of maintenance anaesthetic for aortic surgery
- Volume state and perfusion targets around the clamp
- Blood loss and volume loading during aortic repair
- Repeated clamping and emergence after aortic repair
Peripheral artery disease
- Prevalence, risk factors and surgical indications in peripheral disease
- Intermittent claudication and its natural history
- Inflow versus outflow disease
- Chronic limb ischaemia
- Direct and extra-anatomic reconstruction
- Anaesthesia for aortofemoral bypass
- Anaesthesia for extra-anatomic bypass
- Anaesthesia for infrainguinal revascularisation
- Outcomes after lower extremity revascularisation
Endovascular surgery
- The endovascular era and early carotid stenting
- Stenting versus endarterectomy: the evidence
- Transcarotid artery revascularisation
- When stenting is preferred, and its anaesthetic approach
- Baroreceptor reflex during carotid stenting
- Why endovascular aneurysm repair took over
- Uptake of endovascular repair over time
- Randomised trials of open versus endovascular aneurysm repair
- Choosing between open and endovascular repair
- The EVAR-2 trial
- Risk scores predicting 30-day mortality after endovascular aneurysm repair
- Risk scores predicting 30-day mortality after endovascular aneurysm repair (continued)
- Interpreting the endovascular mortality risk score
- The EVAR risk assessment model
- Early endografts and the landing zone problem
- Fenestrated, branched and chimney grafts
- Snorkel and periscope stent configurations
- Evidence base for complex endovascular repair
- Outcomes and stroke risk of chimney repair
- Choice of anaesthetic technique for endovascular repair
- Evidence on anaesthetic technique for endovascular repair
- Conversion risk and events during stent deployment
- Rupture management and when central access is worth placing
- Intraoperative requests and completing the procedure
- Reintervention burden and the endoleak
- Types of endoleak after endovascular aneurysm repair
- Type I and type III endoleaks
- Type II endoleak
- Type IV and type V endoleaks
- Endoleak as the driver of late open conversion
- Stent graft migration, infection and kinking
- Renal damage and contrast nephropathy after endovascular repair
- Practice trends and hybrid procedures in peripheral disease
- Evidence for open versus endovascular peripheral repair
- Infrapopliteal intervention and its anaesthetic management
Summary and key points
- Patient profile in vascular surgery
- Where risk lies and where the field is heading
- Key points from this topic
- Numbers worth remembering from this topic
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition