1. Coronary Artery Disease in Patients with Peripheral Vascular Disease. The presence of uncorrected coronary artery disease appears to double the 5-year mortality rate after vascular surgery.
   1. Percutaneous coronary interventions (PCIs) directed at reducing perioperative cardiac events do not appear to reduce perioperative myocardial infarction (MI); however, PCI performed in the distant past may be protective after vascular surgery.
   2. In the first 6 weeks after coronary stent placement, noncardiac surgery carries considerable risks. There are two basic types of stents: bare metal stents and drug-eluting stents. Although drug-eluting stents have a reduced incidence of restenosis, they are slow to endothelialize, and the exposed stent material remains thrombogenic far longer than bare metal stents. Therefore, the duration of dual antiplatelet therapy (aspirin 325 mg/day and clopidogrel 75 mg/day) differs: 1 month for bare-metal stents, 12 months or more for drug-eluting stents.
   3. Guidelines suggest continuing aspirin therapy in all patients with a coronary stent and discontinuing clopidogrel for as short a time interval as possible for patients with bare-metal stents for an <30 days or drug-eluting stents for <1 year.
      1. Two distinct types of perioperative MI (PMI)—“early” and “delayed”—occurring after vascular surgery have been identified.
      2. Early PMI resembles that of acute nonsurgical MI and is probably attributable to acute coronary occlusion resulting from plaque rupture and thrombosis.
      3. The “delayed PMI” is associated with sustained elevation of heart rate, absence of chest pain, and prolonged premonitory episodes of ST segment depression before overt MI. The delayed PMI resembles that resulting from increase in oxygen demand in the setting of fixed coronary stenosis.
   4. Guidelines from the American Heart Association and American College of Cardiology classify the clinical predictors of increased perioperative cardiovascular risk (MI, congestive heart failure, and death) as “major,” “intermediate,” and “minor.” (Table 39-2: Pharmacologic Prophyaxis Agains Acute Vascular Events in Patients Undergoing Vascular Surgery).
2. Preoperative Coronary Revascularization. Myocardial revascularization may have long-term benefits in patients with triple-vessel coronary disease or poor left ventricular function. However, mortality rates associated with these techniques are consistently higher in patients with peripheral vascular disease compared with those without. Whether preoperative coronary revascularization actually protects against perioperative cardiac events is controversial.

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