
Peripheral Arterial Disease (PAD) & Cerebrovascular Disease (CVD)
ASSESSMENT
Data Gathering
History
Symptoms
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Previous cardiovascular disease
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Previous stroke or TIA (presenting symptoms, work-up, treatment)
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Previous evaluation for cardiovascular disease & stroke (eg, carotid ultrasound, brain MRI, ABIs, angiography)
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History of revascularizations
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Numbness/weakness/paresthesias
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Aphasia
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Cognitive deficits
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Claudication
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Lightheadedness
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Visual loss
Exam
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Carotid bruits
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Peripheral pulses
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Focal neurologic deficits
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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
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BMP within 4 months if non-low-risk surgery
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ECG within 6 months if non-low-risk surgery
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Arterial-brachial indices (ABIs) should generally be obtained as indicated in any setting (ie, with signs/symptoms of PAD)
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Echocardiogram indicated if patient has history of CVA or TIA with no previous echocardiogram
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CAROTID ULTRASOUND (OR OTHER CAROTID IMAGING)
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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)
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Obtain in the following situations:
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CVA or TIA with no previous carotid imaging
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Presence of a carotid bruit and at least one of the following (Choosing Wisely):
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Age >65
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Coronary artery disease
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Need for coronary bypass
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PAD
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Hyperlipidemia
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Tobacco use
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MANAGEMENT
Indications for Surgical Delay
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CVA within 6-9 months (Jørgensen et al, Christiansen et al)
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If urgent surgery required, may be best to operative within first 3 days after stroke (Christiansen et al)
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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)
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Carotid stenosis meeting criteria for intervention and scheduled for non-urgent surgery
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Severe carotid stenosis and planned surgery will be performed in sitting position (eg, shoulder surgery)
Medication Management
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ACC/AHA guidelines recommend continuation of antiplatelet therapy if the thrombotic risks outweigh the bleeding risks (ACC/AHA guideline):
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Author recommends continuing if possible (after discussion with surgeon) for patients with ischemic CVA/TIA within past year and peripheral arterial revascularization
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All patients with PAD/CVD have an indication for high-dose statin therapy - continue or initiate this unless patient has a contraindication
COUNSELING & COMMUNICATION
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Collaborate with patients' cardiologists, neurologists, and vascular medicine specialists
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Provide anesthesiology with advance notice of patient's with recent CVA, so appropriate intraoperative care plans can be made
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For lower extremity procedures, inform surgeon of patients with peripheral revascularization since this may make use of a tourniquet contraindicated
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Share with patients that current risk estimation tools do not accurately account for the risks related to CVD/PAD
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The risk for CV events and mortality is substantially increased in patients with recent CVD (Jørgensen et al):
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Mortality – OR 4.4 within 3 months
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CVA – OR 19.0 within 6 months
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MI – OR 5.4 within 6 months
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