Critical Care and Perioperative Management of the Vascular Patient
Preoperative risk
Cardiac events are the leading cause of perioperative death in vascular surgery. Use the revised cardiac risk index and functional capacity to decide who needs stress testing; do not delay urgent limb salvage for testing in an asymptomatic patient. Continue beta blockers in those already taking them, but do not start them on the day of surgery - POISE showed fewer myocardial infarctions but more strokes and deaths. Continue statins and aspirin. Avoid interrupting dual antiplatelet therapy within 30 days of a bare-metal coronary stent or within the recommended window after a drug-eluting stent; discuss with cardiology rather than stopping unilaterally.
Intraoperative and postoperative care
Goal-directed fluids, normothermia, and avoidance of hypotension protect grafts and kidneys. Check troponin and ECG in high-risk patients, because most perioperative infarctions are silent. Use a restrictive transfusion threshold of about 7–8 g/dL unless there is active ischemia. Acute kidney injury follows contrast, hypotension, and atheroembolism. Watch intra-abdominal pressure after ruptured AAA repair and limb compartments after prolonged ischemia.
Specific syndromes
Spinal cord ischemia after thoracic aortic repair presents as delayed paraparesis - augment pressure and drain cerebrospinal fluid. Agitation after carotid endarterectomy may be hyperperfusion rather than stroke. Postoperative delirium often signals hypoxia, pain, or sepsis rather than a new neurologic event.
Rule of thumb: after major vascular surgery, unexplained tachycardia or hypotension is myocardial infarction or bleeding until proven otherwise.