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Oxford Specialist Handbooks published and forthcoming
General Oxford Specialist Handbooks Oxford Specialist Handbooks
A Resuscitation Room Guide in Oncology
Addiction Medicine Practical Management of Complex
Day Case Surgery Cancer Pain
Perioperative Medicine, 2e Oxford Specialist Handbooks
Pharmaceutical Medicine in Paediatrics
Postoperative Complications, 2e
Renal Transplantation Paediatric Dermatology
Paediatric Endocrinology and
Oxford Specialist Handbooks Diabetes
in Anaesthesia Paediatric Gastroenterology,
Anaesthesia for Medical and Surgical Hepatology, and Nutrition
Emergencies Paediatric Haematology and
Cardiac Anaesthesia Oncology
Neuroanaesthesia Paediatric Intensive Care
Obstetric Anaesthesia Paediatric Nephrology, 2e
Ophthalmic Anaesthesia Paediatric Neurology, 2e
Paediatric Anaesthesia Paediatric Radiology
Regional Anaesthesia, Stimulation and Paediatric Respiratory Medicine
Ultrasound Techniques Paediatric Rheumatology
Thoracic Anaesthesia Oxford Specialist Handbooks
Vascular Anaesthesia in Pain Medicine
Oxford Specialist Handbooks Spinal Interventions in Pain
in Cardiology Management
Adult Congenital Heart Disease Oxford Specialist Handbooks
Cardiac Catheterization and Coronary in Psychiatry
Intervention
Cardiac Electrophysiology and Catheter Child and Adolescent Psychiatry
Ablation Forensic Psychiatry
Cardiovascular Computed Tomography Old Age Psychiatry
Cardiovascular Magnetic Resonance Oxford Specialist Handbooks
Echocardiography, 2e in Radiology
Fetal Cardiology Interventional Radiology
Heart Failure Musculoskeletal Imaging
Hypertension Pulmonary Imaging
Inherited Cardiac Disease Thoracic Imaging
Nuclear Cardiology
Pacemakers and ICDs Oxford Specialist Handbooks
Pulmonary Hypertension in Surgery
Valvular Heart Disease Cardiothoracic Surgery, 2e
Colorectal Surgery
Oxford Specialist Handbooks Gastric and Oesophageal Surgery
in Critical Care Hand Surgery
Advanced Respiratory Critical Care Hepatopancreatobiliary Surgery
Cardiothoracic Critical Care Neurosurgery
Oxford Specialist Handbooks Operative Surgery, 2e
in End of Life Care Oral and Maxillofacial Surgery
End of Life Care in Cardiology Otolaryngology and Head and Neck
End of Life Care in Dementia Surgery
End of Life Care in Nephrology Paediatric Surgery
End of Life Care in Respiratory Disease Plastic and Reconstructive Surgery
End of Life in the Intensive Care Unit Surgical Oncology
Urological Surgery
Oxford Specialist Handbooks Vascular Surgery
in Neurology
Epilepsy
Parkinson’s Disease and Other Movement
Disorders
Stroke Medicine
Oxford Specialist Handbooks
in Anaesthesia
Vascular Anaesthesia
Edited by

Dr Jonathan P. Thompson
Senior Lecturer in Anaesthesia and Critical Care
Department of Cardiovascular Sciences
University of Leicester
and
Honorary Consultant in Anaesthesia and Critical Care
University Hospitals of Leicester NHS Trust
Leicester
UK

Dr Simon J. Howell
Senior Lecturer in Anaesthesia
Biomedical and Clinical Sciences
University of Leeds
Leeds
UK

Dr Richard J. Telford
Consultant Anaesthetist
Royal Devon and Exeter Foundation NHS Trust
Exeter
UK

1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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The moral rights of the authors have been asserted
First edition published in 204
Impression: 
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retrieval system, or transmitted, in any form or by any means, without the prior
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recent codes of conduct and safety regulations. The authors and the publishers
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drug dosages and recommendations are for the non-pregnant adult who is not
breastfeeding.
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 v

Foreword

Anaesthesia for vascular surgery is possibly one of the most challenging fields
of our clinical practice. By virtue of their primary surgical pathology and its
associated risk factors, patients have a very high incidence of co-morbidities,
particularly hypertension, diabetes, cardiac, cerebrovascular, renal and respira-
tory disease. Advances in anaesthesia must also keep abreast of surgical and
graft developments which have led to a dramatic increase in the use of endo-
vascular stents such that they now constitute the majority of surgery. In turn,
however, this has resulted in the presentation of patients previously regarded
as medically unsuitable for surgery since the perturbations of surgical trauma
are markedly reduced. At the same time, open repair of aneurysmal and sten-
otic disease is still an option for some and may be unavoidable for anatomical
reasons in others. Patients with complex pathology may require hybrid proce-
dures which entail an open surgical component in addition to graft placement.
Further still, correction of graft complications and leaks may necessitate more
complicated open surgery. Hence the traditional skills for handling clamping
and unclamping of the aorta and major haemodynamic disturbance must be
preserved. Perioperative organ protective is pivotal to optimising patient out-
come. There is also a need to protect the kidney from ischaemia and contrast
induced nephropathy, the spinal cord during open or endovascular aortic sur-
gery, the brain in carotid surgery and the heart in all surgery. An understand-
ing of appropriate monitoring of these organs, techniques for protection both
pharmacologic and mechanical, appropriate use of anaesthetic and other drugs
and amelioration of ischaemia-reperfusion injury is essential. Knowledge of
regional anaesthesia, peripheral nerve blocks and sedation techniques is also
important for anaesthesia and analgesia in many of these patients. A successful
outcome is only as “strong as the weakest link” and both preoperative prepara-
tion and postoperative care are integral facets. In negotiating all these aspects
of patient care, vascular anaesthetists can truly be considered model periop-
erative physicians.
Recent developments in both surgery and perioperative care make this
an apposite time to produce this handbook and the editors, all very expe-
rienced and authoritative in this field, have collected an eclectic collection
of clinicians to present a clear and easy to read overview of this challenging
specialty. True to its status as a handbook, chapters are succinct, easy to
read and search with appropriate use of bullet points and avoidance of
verbosity. An excellent companion for the busy clinician both in training and
those seasoned in practice.
Professor Michael G. Irwin MB ChB MD DA FRCA FANZCA FHKAM
Head, Dept of Anaesthesiology
University of Hong Kong
Chief of Service
Queen Mary Hospital / HKU Shenzhen Hospital
K424, Queen Mary Hospital
Pokfulam Road
Hong Kong
 vii

Preface

The management of the patient with vascular disease is evolving rapidly.

Population screening for vascular disease has been introduced and its effects
on practice are being evaluated. The management of associated medical
conditions is also changing. New guidelines have been published for the
management of acute coronary syndromes, stable coronary heart disease,
diabetes, implantable pacemakers, and defibrillators. Decisions regarding
surgical intervention and anaesthetic management remain complicated due
to the co-existence of vascular disease at other sites or other co-morbid
conditions, but have been aided by improved approaches to preopera-
tive risk assessment, perioperative monitoring and postoperative care.
Radiological expertise and procedures are increasingly used to treat condi-
tions previously treated by open surgery, such as aortic aneurysms, occlu-
sive lower limb arterial disease, or carotid disease. Priorities have evolved
so that carotid endarterectomy is now performed as an urgent procedure
after TIA or minor stroke. In addition, the pace of change over the last two
decades has made it difficult for those involved in the care of the vascular
surgical patient to remain updated with recent progress in perioperative
management. The literature describes an increasing array of techniques for
preoperative investigation and monitoring during anaesthesia, with dispa-
rate evidence and recommendations. When faced in clinical practice with
a patient with vascular disease, the anaesthetist needs to know what to do
and when to do it, as well as what not to do and why.
In this new addition to the Oxford Specialist Handbooks series we have
tried to produce a concise volume that will enable the vascular practi-
tioner (in its broadest sense) to adopt a practical, current, evidence-based
approach to all aspects of perioperative care for the patient with vascular
disease, particularly those undergoing interventional radiological, diagnos-
tic, and surgical procedures. Although primarily aimed at anaesthetists, we
hope the book will be relevant to vascular nurses, theatre practitioners,
trainees in Intensive Care Medicine and possibly even vascular surgeons.
Our approach has been to combine essential background knowledge with
useful, clinically relevant sections on management, so the book can be used
to enhance awareness of potential problems, as an aid to revision, but also
as a practical ‘How to do it’ guide for patient management.
The book is divided into sections and starts with what we consider
essential details on the epidemiology of vascular disease, followed by rel-
evant anatomy and pathophysiology. Good preoperative evaluation is vital
to a successful outcome, but the vascular anaesthetist must also be aware
of the processes involved in complex surgical decision-making; these are
detailed together. Current approaches to risk assessment and risk reduction
are emphasized, including advice on how to set up and run a preoperative
assessment clinic. In the sections on medical management of common co-
existing diseases, monitoring, practical procedures and common regional
anaesthetic techniques, we have tried to summarize what the practitioner
needs to know for everyday practice, based on the most recent data.
viii PREFACE

Radiologists are taking an ever greater role in the care of the vascular
patient; this can be a difficult and complex area of practice and we have
deliberately included a section dedicated to radiological management. The
final three sections are intended to be a convenient guide to the manage-
ment of different vascular procedures and complications during and after
surgery. They are intended to be used as an ‘aide-memoire’ for periopera-
tive care and include guidance on the management of common postopera-
tive problems.
The contributors are all experienced clinicians actively caring for patients
with vascular diseases. They are predominantly consultant anaesthetists
with a special interest in vascular anaesthesia, but include vascular surgeons,
radiologists, cardiologists and other physicians. We hope this book will fulfil
its aims and be useful, relevant and helpful in the day-to-day management
of the vascular surgical patient.
Jonathan P. Thompson
Simon J. Howell
Richard J. Telford
March 203
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 ix

Contents

Symbols and Abbreviations╇ x

Contributors╇ xx

 Epidemiology of vascular disease ╇╇

2 Anatomy physiology and responses to
vascular surgery ╇25
3 Evaluation of the vascular surgical patient ╇85
4 Management of specific medical conditions
and medications 59
5 Principles of perioperative care 22
6 Practical procedures, regional anaesthesia,
and pain management in vascular surgery 25
7 Monitoring of the vascular patient 3
8 Anaesthesia for vascular radiology 333
9 Management of patients undergoing specific
elective vascular procedures 349
0 Emergencies in vascular surgery 447
 Post-operative management 467

Index╇ 525
x

Symbols and
Abbreviations
° primary
2° secondary
< less than
> more than
+ve positive
–ve negative
AAA abdominal aortic aneurysms
AbCS abdominal compartment syndrome
ABG arterial blood gases
ABPI ankle brachial pressure index
ACC American College of Cardiology
ACE angiotensin-converting enzyme
AcLI acute limb ischaemia
ACS acute coronary syndrome
ACST Asymptomatic Carotid Surgery Trial
ACT activated clotting times
ADH anti-diuretic hormone
ADP adenosine di-phosphate
AF atrial fibrillation
AHA American Heart Association
AKA above knee amputations
AKI acute kidney injury
ALI acute lung injury
ANH acute normovolaemic haemodilution
ANP atrial natriuretic peptide
AP anteroposterior
APC abnormalities of protein C
APL adjustable pressure limiting
APTT activated partial thromboplastin time
APTTR activated partial thromboplastin time ratio
ARB angiotensin II receptor blocker
ARDS adult respiratory distress syndrome
ARR absolute risk reduction
AT angiotensin
 SYMBOLS AND ABBREVIATIONS xi

ATD adult therapeutic dose

ATh anaerobic threshold
AU aggregation units
AUC area under the concentration curve
AUI aorto-uniiliac
AV atrioventricular
AVM arteriovenous malformations
AXC aortic cross-clamp
BAE bronchial artery embolization
BAEP brainstem auditory-evoked responses
bd twice daily
BioMS biomedical scientist
BIS bispectral index
Biv-CRT biventricular cardiac resynchronization therapy
BKA below knee amputations
BMI body mass index
BMS bare metal stents
BNP brain natriuretic peptide
BP blood pressure
BPEG British Pacing and Electrophysiology Group
CABG coronary artery bypass grafting
CAD coronary artery disease
CAS carotid angioplasty with stenting
CBF cerebral blood flow
CCB calcium channel blocker
CCU critical care unit
CEA carotid endarterectomy
CePB cervical plexus block
CFAM cerebral function analysing monitor
CGRP calcitonin gene-related peptide
CH cerebral hyperperfusion
CHS cerebral hyperperfusion syndrome
CIN contrast-induced nephropathy
CKD chronic kidney disease
CLI critical limb ischaemia
CMI chronic mesenteric ischaemia
CMV cytomegalovirus
CNS central nervous system
xii SYMBOLS AND ABBREVIATIONS

CO cardiac output
CoNS coagulase –ve staphylococci
COPD chronic obstructive pulmonary disease
CPAP continuous positive airways pressure
CPB cardiopulmonary bypass
CPD continuous peritoneal dialysis
CPET cardiopulmonary exercise testing
CPI Customized Probability Index
CPP cerebral perfusion pressure
CPX cardiopulmonary exercise testing
CSA cross-sectional area
CSE combined-spinal epidural
CSF cerebrospinal fluid
CSpA continuous spinal anaesthesia
CsT closure time
CT computed tomogram
CTA CT angiography
cTN cardiac troponin
CVA central venous access
CVC central venous catheter
CVD cerebrovascular disease
CVI chronic venous insufficiency
CVP central venous pressure
CVR cerebral vascular resistance
CVVH continuous veno-venous haemofiltration
CXR chest X-ray
DBP diastolic blood pressure
DCT distal convoluted tubule
DES drug-eluting stents
DHCA deep hypothermic cardiac arrest
DLT double lumen tube
DM diabetes mellitus
DNIC diffuse noxious inhibitory control
DPG diphosphoglycerate
DRG dorsal root ganglia
DSE dobutamine stress echocardiography
DVT deep vein thrombosis
ECG electrocardiogram
EEG electroencephalogram
 SYMBOLS AND ABBREVIATIONS xiii

EET eicosatrienoic acids

EF ejection fraction
eGFR estimated glomerular filtration rate
EMG electromyogram
eNOS endothelial NO synthase
EPO erythropoietin
ESRD end-stage renal disease
ESRF end stage renal failure
ETS endoscopic thoracic sympathectomy
EVAR endovascular aneurysm repair
EVLA endovenous laser ablation
EVLT endovenous laser treatment
EWS Early Warning Score
FAST focused assessment with sonography in trauma
FBC full blood count
FDP fibrin degradation products
FEV forced expiratory volume
FFP fresh frozen plasma
FMR functional mitral regurgitation
FPG fasting plasma glucose
FRC functional residual capacity
FTc flow time corrected for heart rate
G&S group & save
GA general anaesthesia/anaesthetic
GCS Glasgow Coma Score
GDT goal-directed therapy
GFR glomerular filtration rate
GI gastrointestinal
GIB gastrointestinal bleeding
GP general practitioner
GRACE Global Registry of Acute Coronary Events
GTN glyceryl trinitrate
Hct haematocrit
Hcy homocysteine
HDU high dependency unit
HF heart failure
HHcy hyperhomocysteinaemia
HIT heparin-induced thrombocytopenia
HITT heparin-induced thrombocytopenia and thrombosis
xiv SYMBOLS AND ABBREVIATIONS

HME heat and moisture exchanger

hsCRP high sensitivity C-reactive protein
IABP invasive arterial blood pressure
IAH intra- abdominal hypertension
IAP intra-abdominal pressure
IBP intra-arterial blood pressure
IC intermittent claudication
ICD implantable cardiac defibrillators
ICP intracranial pressure
ICS intracoronary stents
ICU intensive care unit
IFG impaired fasting glycaemia
IGT impaired glucose tolerance
IHD ischaemic heart disease
IIA internal iliac artery
IJV internal jugular vein
iNOS inducible nitric oxide synthase
INR international normalized ratio
IOCS intraoperative cell salvage
IPPV intermittent positive pressure ventilation
IR interventional radiology
ISWT incremental shuttle walking test
ITU intensive therapy unit
IV intravenous
IVC inferior vena cava
JVP jugular venous pressure
KATP adenosine triphosphate (ATP)-sensitive potassium
(K+) channel
KDIGO Kidney Disease: Improving Global Outcomes
LA local anaesthesia/anaesthetic
LBBB left bundle branch block
LCA left coronary artery
LDL low density lipoprotein
LFT liver function test
LiDCO lithium indicator dilution
LIJ left internal jugular
LLA lower limb amputation
LLL left lower lobe
LMA laryngeal mask airway
 SYMBOLS AND ABBREVIATIONS xv

LMWH low molecular weight heparin

LUL left upper lobe
LV left ventricle/ventricular
LVEDP left ventricular end-diastolic pressure
LVEF left ventricular ejection fraction
LVF left ventricular failure
MA mean acceleration
MAC minimum alveolar concentration
MAP mean arterial pressure
MASS Multicentre Aneurysm Screening Study
MCA middle cerebral artery
MCF maximum clot firmness
MDRD modification of diet in renal disease
MDT multidisciplinary team
MEP motor-evoked potential
MET metabolic equivalent
MEWS Modified Early Warning Score
MI myocardial infarction
MR modified release
MRA magnetic resonance angiography
MRI magnetic resonance imaging
MRSA meticillin-resistant Staphylococcus aureus
MTPP mitochondrial transition permeability pore
NANC non-adrenergic non-cholinergic
NASSE North American Society of Pacing and Electrophysiology
NGAL Neutrophil gelatinase-associated lipocalin
NGT nasogastric tube
NHANES National Health and Nutrition Examination Survey
NIBP non-invasive blood pressure
NICE National Institute of Health and Care Excellence
NIRS near infrared spectroscopy
NMB neuromuscular blockers
NMDA N-methyl-d-aspartate
nNOS neural nitric oxide synthase
NNT numbers needed to treat
NO nitric oxide
NPV negative predictive value
NSAID non-steroidal anti-inflammatory drug
NSTEMI non-ST segment elevation myocardial infarction
xvi SYMBOLS AND ABBREVIATIONS

NT-proBNP N-terminal pro-BNP

NVD national vascular database
NYHA New York Heart Association
ODM oesophageal Doppler monitoring
ODP operating department practitioner
OGTT oral glucose tolerance test
OIH opioid-induced hyperalgesia
OLV one-lung ventilation
PA pulmonary artery
PAC pulmonary artery catheter
PACU post-anaesthesia care unit
PAD peripheral arterial disease
PAOP pulmonary artery occlusion pressure
PbrO2 brain tissue O2 partial pressure
PCA patient-controlled analgesia
PCC prothrombin complex concentrate
PCEA patient-controlled epidural analgesia
PCI percutaneous coronary intervention
PCR polymerase chain reaction
PCT proximal convoluted tubule
PCV packed cell volume
PCWP pulmonary capillary wedge pressure
PE pulmonary embolism
PEEP positive end expiratory pressure
PES post-embolization syndrome
PICC peripherally-inserted central catheters
PIP peak inspiratory pressure
PKCε proteinkinase C espsilon
PLP phantom limb pain
po by mouth
POC point of care
POCD post-operative cognitive dysfunction
POISE perioperative ischaemia evaluation
PONV post-operative nausea and vomiting
PPC post-operative pulmonary complication
PPV positive predictive value
PreAD preoperative autologous donation
PSIS posterior superior iliac spine
PT prothrombin time
 SYMBOLS AND ABBREVIATIONS xvii

PTFE polytetrafluoroethylene
PTH parathyroid hormone
PTT partial thromboplastin time
PuPV pulse pressure variation
PV peak velocity
PVC premature ventricular contractions
PVD peripheral vascular disease
PVGI prosthetic vascular graft infection
PVR peripheral vascular reconstruction
RA regional anaesthesia/anaesthetic
RAAA ruptured open abdominal aortic aneurysm repair
RAAS renin-angiotensin-aldosterone system
RBC red blood cells
RBF renal blood flow
RCA right coronary artery
RCRI revised cardiac risk index
RCT randomized controlled trial
RFA radiofrequency ablation
RIJ right internal jugular
RLL right lower lobe
RMB right main bronchus
RML right middle lobe
RMP resting membrane potential
ROC receiver operating characteristic
RPF renal plasma flow
RR respiratory rate
RRR relative risk reduction
RRT renal replacement therapy
r-TEG rapid-TEG
rtPA recombinant tissue plasminogen activator
RUL right upper lobe
RV right ventricle
SA sino-atrial
SACU surgical acute care unit
SAG-M saline, adenine, glucose, and mannitol
SAM S-adenosylmethionine
SBP systolic blood pressure
sc subcutaneous
SCM sternocleidomastoid
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