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Peripheral Arterial Disease (PAD) & Cerebrovascular Disease (CVD)

ASSESSMENT

Data Gathering

History

Symptoms

  • Previous cardiovascular disease

  • Previous stroke or TIA (presenting symptoms, work-up, treatment)

  • Previous evaluation for cardiovascular disease & stroke (eg, carotid ultrasound, brain MRI, ABIs, angiography)

  • History of revascularizations

  • Numbness/weakness/paresthesias

  • Aphasia

  • Cognitive deficits

  • Claudication

  • Lightheadedness

  • Visual loss

Exam

  • Carotid bruits

  • Peripheral pulses

  • Focal neurologic deficits

  • Pallor/hair loss on distal extremities

Risk Stratification

No well-validated perioperative risk stratification tools​ specific for PAD or CVD have been developed. Risk stratification should be focused on assuring these have been appropriately evaluation and are optimally managed.

Diagnostic Studies

  • BMP within 4 months if non-low-risk surgery

  • ECG within 6 months if non-low-risk surgery

  • Arterial-brachial indices (ABIs) should generally be obtained as indicated in any setting (ie, with signs/symptoms of PAD)

  • Echocardiogram indicated if patient has history of CVA or TIA with no previous echocardiogram

  • CAROTID ULTRASOUND (OR OTHER CAROTID IMAGING)

    • Still much debate about screening prior to surgery, but prevailing opinion remains in line with recommendations for general population - no indication in asymptomatic patients without a bruit and risk factors for significant carotid stenosis (Choosing Wisely)

    • Obtain in the following situations:

      • CVA or TIA with no previous carotid imaging​

      • Presence of a carotid bruit and at least one of the following (Choosing Wisely):

        • Age >65

        • Coronary artery disease

        • Need for coronary bypass

        • PAD

        • Hyperlipidemia

        • Tobacco use

MANAGEMENT

Indications for Surgical Delay

  • CVA within 6-9 months (Jørgensen et al, Christiansen et al, AHA/Am Stroke Assoc)

    • Delay surgery at least 3 months per most recent study (Glance et al) after CVA, but AHA/American Stroke Associate Position Statement produced before this suggests 6 months and optimally 9 months, after CVA (AHA/Am Stroke Assoc)

    • If urgent surgery required, may be best to operative within first 3 days after stroke (Christiansen et al)​

  • Evidence of significant arterial insufficiency in same extremity that will undergo major procedure (author opinion based on concern for wound healing - primarily with lower extremity procedures​ below the thigh)

  • Carotid stenosis meeting criteria for intervention and scheduled for non-urgent surgery

  • Symptomatic carotid stenosis of >70% should be revascularized prior to elective surgery (Benesch et al)​

  • Severe carotid stenosis and planned surgery will be performed in sitting position (eg, shoulder surgery)

Medication Management

  • ACC/AHA guidelines recommend continuation of antiplatelet therapy if the thrombotic risks outweigh the bleeding risks (ACC/AHA guideline)​:

    • Author recommends continuing if possible (after discussion with surgeon) for patients with ischemic CVA/TIA within past year and peripheral arterial revascularization

  • All patients with PAD/CVD have an indication for high-dose statin therapy - continue or initiate this unless patient has a contraindication​

COUNSELING & COMMUNICATION

  • Collaborate with patients' cardiologists, neurologists, and vascular medicine specialists

  • Provide anesthesiology with advance notice of patient's with recent CVA, so appropriate intraoperative care plans can be made

  • For lower extremity procedures, inform surgeon of patients with peripheral revascularization since this may make use of a tourniquet contraindicated

  • Share with patients that current risk estimation tools do not accurately account for the risks related to CVD/PAD

    • The risk for CV events and mortality is substantially increased in patients with recent CVD (Jørgensen et al):​

      • Mortality – OR 4.4 within 3 months

      • CVA – OR 19.0 within 6 months

      • MI – OR 5.4 within 6 months

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