1. Pathophysiology of Atherosclerosis. Atherosclerosis is a generalized inflammatory disorder of the arterial tree with associated endothelial dysfunction. The commonly accepted causes of atherosclerosis are endothelial damage (injury) caused by hemodynamic shear stress, inflammation from chronic infections, hypercoagulability resulting in thrombosis, and the destructive effects of oxidized low-density lipoproteins (Table 39-1: Clinical Predictors of Increased Periopeartive Risk for Myocardial Infarction, Congestive Heart Failure, and Death).
2. Natural History of Patients with Peripheral Vascular Disease (Fig. 39-1: Approximate range of odds ratios for risk factors for symptomatic peripheral arterial disease)
   1. Atherosclerosis must be recognized as a systemic disease with important sequelae in many other regional circulations (coronary atherosclerosis, stroke, abdominal aortic aneurysm [AAA], peripheral arterial disease) (Fig. 39-2: Typical overlap in vascular disease affecting different organ systems).
   2. Noninvasive angiography (magnetic resonance angiography and computed tomographic angiography) enable excellent noninvasive definition of the vascular anatomy.
   3. AAAs occur in up to 5% of men older than 65 years of age. (The risk of rupture is very low for aneurysms ≤4 cm in diameter but rises exponentially for aneurysms >5 cm.)
3. Medical Therapy for Atherosclerosis
   1. Continuation of chronic medical therapy, including use of antihypertensives such as β-blockers and angiotensin-converting enzyme (ACE) inhibitors, statin drugs, aspirin, and control of hyperglycemia with hypoglycemics or insulin, may reduce perioperative morbidity and mortality in vascular surgery.
   2. ACE inhibitors have numerous beneficial effects in patients with arteriosclerotic vascular disease, including plaque stabilization. Cessation of smoking may be the most effective “medical” therapy.

Anesthesia for Vascular Surgery

1. Vascular Disease: Epidemiologic Medical and Surgical Aspects
2. Chronic Medical Problems and Management in Vascular Surgery Patients
3. Other Medical Problems in Vascular Surgery
4. Organ Protection in Vascular Surgery Patients
5. Carotid Endarterectomy
6. Aortic Reconstruction
7. Lower Extremity Revascularization