Prevalence

• 12–14% of individuals in the general population (3).
• 20% of individuals over the age of 70 years (3).
• 1 in 3 diabetics over the age of 50 years (3).
• Endovascular procedures are increasing in frequency; approximately 1,300 endovascular abdominal aortic aneurysm (AAA) repairs are performed each year in the US.

50% of affected patients had a major event or surgery in a 6-year time span.

33.2% death rate over 5 years

History

• Duration and progression of PVD, activity level, pain.
• A complete history of the patient's PVD must be supplemented by a thorough investigation of other vascular diseases (cardiovascular, cerebrovascular, renovascular) to help determine the best type of anesthetic, monitoring, and if further workup is necessary.

Signs/Physical Exam

• 5 P's of PVD: Pain, pallor, paresthesia, paralysis, pulselessness
• Auscultate for bruits and palpate for thrills
• Skin examination: Atrophic and shiny, alopecia, dry, scaly, erythema, brittle nails

Labs/Studies

• Electrolytes to assess renal function
• CBC to assess for anemia, quantitative platelet abnormalities
• ECG to check for dysrhythmias, ischemia, infarction
• A cardiac stress test may be indicated to assess function and the potential for ischemia. If the patient has good exercise tolerance, >4 METS, cardiac workup is typically not necessary (however, their PVD may affect activity levels independent of coronary disease and preclude the ability to assess this).
• Pulmonary function testing may be indicated in patients with lung dysfunction, particularly in surgical procedures with the potential for postoperative impairment (thoracic, upper abdominal procedures).

• Anxiolytics can allay increases in BP and heart rate.
• Beta-blockers should be continued and titrated to goal heart rates (3).
• Supplemental oxygen may be appropriate.
• Blood sugar control with IV or SQ insulin as appropriate (3).
• Bronchodilators and steroids may be considered in patients with pulmonary disease.
• Gastric medications such as antacids, prokinetics, and acid reducers should be considered in patients with gastroparesis or delayed gastric emptying.

• If the patient has a history of neurovascular disease, and is deemed not competent, informed consent may have to be obtained from a power of attorney.
• Discuss smoking cessation

• Outcome studies on anesthetic choice for PVD procedures and patients have yielded varying results and conclusions. At this time, recommendations or guidelines applicable to all patients, procedures, and situations do not exist. Rather, risks versus benefits and practicality need to be weighed.
• Epidural and spinal
  • Benefits include the ability to block the endocrine stress response seen with surgery; avoids the need for airway manipulation and controlled ventilation; reduces the potential for blood loss, hemodynamic swings associated with general anesthesia and hypercoagulability; increases blood flow and perfusion to lower extremities and decreases time to ambulation; diminishes need for systematic opioids and their side effects (respiratory complications).
  • Drawbacks include risks associated with neuraxial techniques (infections, hematomas, difficult placement, high spinals, inadvertent intravascular injection) and contraindications with common anticoagulants.
• Peripheral nerve blocks
  • Benefits include the ability to block the endocrine stress response seen with surgery as well as avoid the need for airway manipulation, controlled ventilation, and systemic opioids.
  • Drawbacks include failed or incomplete surgical blocks, local anesthetic systemic toxicity, complications of sedation (hypoxia, hypercarbia), and concerns with anticoagulants (brachial plexus blocks in the thorax).
• General anesthesia
  • Benefits include the potential for a still surgical field, controlled ventilation, and patient preference to not be awake.
• MAC with local anesthetic infiltration should be considered when appropriate as it avoids many of the drawbacks seen with the above mentioned techniques

• Standard ASA monitors
• ECG and ST segment monitoring will help to detect perioperative myocardial ischemia in this high-risk patient population.
• Arterial line placement should be considered in patients with concurrent coronary artery disease, decreased left ventricular function, or for procedures with the potential for large swings in BP and/or require beat-to-beat BP monitoring. Consider pre-induction placement. PVD may make line placement difficult.

Slow and controlled to ensure steady hemodynamics and organ perfusion as well as provide an adequate depth of anesthesia. Heart rate, EKG, and arterial line/NIBP should be carefully monitored and abnormalities treated to optimize myocardial oxygen supply and perfusion.

• The myocardial oxygen supply and demand ratio needs to be optimized. It may be necessary to place more invasive monitors as needed intraoperatively.
• In patients with chronic hypertension, the cerebral perfusion pressure curve may be shifted to the right. A good rule of thumb is to maintain BP within 20% of the patient's baseline.
• Normothermia should be maintained to avoid shivering and increased myocardial oxygen consumption.
• Glycemic control should be considered in long or brittle diabetics.

• Avoid or treat shifts in BP and heart rate.
• Consider "deep" extubation in patients with COPD to avoid bronchospasm.