Similar to aortic surgery, lower-limb revascularization has been revolutionized by the dissemination of endovascular techniques. The three clinical indications for elective surgery for chronic peripheral occlusive disease are (1) claudication, (2) ischemic rest pain or ulceration, and (3) gangrene.
Tunneling of the graft may be more stimulating than other parts of the procedure and may cause hypertension or movement under general anesthesia.
The patient is usually given heparin during the procedure. In most cases, the heparin effect is not antagonized because bleeding problems are rare and graft reocclusion is a concern.
Management of Elective Lower Extremity Revascularization
Data on the effect of the choice of anesthetic technique on outcome after lower extremity surgery suggest that regional anesthesia is associated with a lower incidence of graft failure and pneumonia than general anesthesia. There appears to be no difference between regional and general anesthesia in the 30-day mortality rate.
General anesthesia for lower extremity revascularization has the advantage of obviating patient discomfort and lack of cooperation. Its use is virtually mandated in patients who are to have vein harvested from an arm.
Acute arterial occlusion resulting in severe ischemia (extremity is cold and pulseless) is a surgical emergency.
If the cause is an arterial embolus, Fogarty embolectomy through a groin incision under local anesthesia may suffice, but if the cause is thrombosis of severely diseased atherosclerotic arteries, bypass repair may be required.
Serum potassium levels can change quickly because cell death causes release of intracellular potassium into the circulation. Myoglobin may also be released into the circulation. The development of a compartment syndrome is a possibility; therefore, fasciotomies may be required.