Perioperaive evaluation and management in vascular surgery especially for arteriosclerosis obliterans

Perioperative cardiac event is relatively high in vascular surgery for arteriosclerosis obliterans (ASO), which is a major cause of postoperative death. ACC/AHA guideline and revised cardiac risk index (CRI) were advocated to assess risk factor stratification and to manage risk reduction. ACC/AHA guideline categorized all vascular procedures except carotid endarterectomy as high risk. Because almost all patients with ASO were aged and/or inactive, noninvasive testing was necessary in almost all patients by the stepwise bayesian strategy. Patients with revised CRI less than 1 point dominated about three fourths of all patients, whose prevalence and incidence of ischemic heart disease (IHD) were 2.5% and 1.3%, respectively. It seemed appropriate to apply noninvasive testing only for patients with revised CRI more than 2 points, and high risk indicated coronary angiography. Electrocardigrams obtained at baseline, immediately, and on the first 2 days after surgery appear to be cost-effective to diagnose IHD. Use of cardiac biomarkers was reserved for patients at high risk and those with clinical, or ECG evidence of myocardial infarction (MI). Beta-blockers or alpha-agonists were effective to reduce incidence of perioperative IHD. Although even optimal preoperative assessment and perioperative management, some patients will have perioperative MI.