Perioperative management of lower extremity revascularization

Anesthetic management for lower extremity vascular bypass procedures: The impact of general or regional anesthesia on clinical outcomes

PURPOSE

Postoperative complications after major surgery, especially vascular procedures, are associated with a significant increase in costs and mortality. Previous studies evaluating general anesthesia versus regional or neuraxial anesthesia for infrainguinal bypass have produced conflicting results. The main aim of the present study is to review current evidence on the application of regional or general anesthesia in patients undergoing infrainguinal bypass surgery and its potential favorable effects on postoperative outcomes.

CONTENTS

Patients undergoing vascular surgery often have multiple comorbidities, and it is important to outline both benefits and risks of regional anesthesia techniques. Neuraxial anesthesia in vascular surgery allows overall avoidance of general anesthesia and does provide short-term benefits beyond analgesia. Previous observational studies suggest that neuraxial anesthesia for lower limb revascularization may reduce morbidity and length of stay. However, evidence of long-term benefits is lacking in most procedures and further work is still warranted.

CONCLUSIONS

Neuraxial anesthesia is usually an effective anesthesia technique for infrainguinal bypass surgery. Elderly patients and those with underlying respiratory problems may display some benefit from neuraxial anesthesia. Further evaluation within institutions should be performed to identify which patients would most benefit from regional techniques. Notably, systemic antithrombotic and anticoagulation therapy is common among this population and may affect anesthetic choices.

Impact of regional anesthesia on outcomes of geriatric patients undergoing lower extremity revascularization: A propensity score-matched cohort study

Lower extremity revascularization (LER) for peripheral artery disease in elderly patients is associated with a high risk of perioperative morbidity and mortality. This study aimed to a conduct retrospective review and propensity score matching analysis to determine whether the use of regional anesthesia (RA) instead of general anesthesia (GA) in geriatric patients undergoing LER for peripheral artery disease results in improved short-term mortality and health outcomes. We reviewed medical records of 1271 patients aged >65 years who underwent LER at our center between May 1998 and February 2016. According to the anesthesia method, patients were grouped in the GA and RA groups. The primary outcome was short-term mortality (7-day and 30-day). The secondary outcomes were 5-year survival rate, intraoperative events, postoperative morbidity, and postoperative length of stay. A propensity score-matched cohort design was used to control for potentially confounding factors including patient demographics, comorbidities, American Society of Anesthesiologists physical status, and preoperative medications. After propensity score matching, 722 patients that received LER under GA (n = 269) or RA (n = 453) were identified. Patients from the GA group showed significantly higher 7-day mortality than those from the RA group (5.6% vs 2.7% P = .048); however, there was no significant difference in 30-day mortality between the groups (GA vs RA: 6.3% vs 3.6%, P = .083). The 5-year survival rate and incidence of arterial and central venous catheter placement or intraoperative dopamine and epinephrine use were significantly higher in the GA group than in the RA group (P < .05). In addition, the frequency of immediate postoperative oxygen therapy or mechanical ventilation support was higher in the GA group (P < .05). However, there was no difference in the postoperative cardiopulmonary and cerebral complications between the 2 groups. These results suggest that RA can reduce intraoperative hemodynamic support and provide immediate postoperative respiratory intensive care. In addition, the use of RA may be associated with better short-term and 5-year survival rates in geriatric patients undergoing LER.

Use Of Regional Anesthesia For Lower Extremity Amputation May Reduce The Need For Perioperative Vasopressors: A Propensity Score-Matched Observational Study

Purpose

Lower extremity amputation (LEA) is associated with a high risk of postoperative mortality. The effect of type of anesthesia on postoperative mortality has been studied in various surgeries. However, data for guiding the selection of optimal anesthesia for LEA are limited. This study aimed to determine the effect of anesthesia type on perioperative outcomes in patients with diabetes and/or peripheral vascular disease undergoing LEA.

Patients and methods

We reviewed the medical records of patients who underwent LEA at our center between September 2007 and August 2017, who were grouped according to use of general anesthesia (GA) or regional anesthesia (RA). Primary outcomes were 30-day and 90-day mortality. Secondary outcomes were postoperative morbidity, intraoperative events, postoperative intensive care unit admission, and postoperative length of stay. Propensity score-matched cohort design was used to control for potentially confounding factors, including patient demographics, comorbidities, medications, and type of surgery.

Results

Five hundred and nineteen patients (75% male, mean age 65 years) were identified to have received GA (n=227) or RA (n=292) for above-knee amputation (1.5%), below-knee amputation (16%), or more minor amputation (82.5%). Before propensity score matching, there was an association of GA with coronary artery disease (44% [GA] vs 34.5% [RA], p=0.028), peripheral arterial disease (73.1% vs 60.2%, p=0.002), and preoperative treatment with aspirin and clopidogrel (68.7% vs 55.1%, p=0.001; 63% vs 41.8%, p<0.001, respectively). Propensity score matching produced a cohort of 342 patients equally divided between GA and RA. There was no significant between-group difference in 30-day (3.5% vs 2.9%, p=0.737) or 90-day (6.4% vs 4.6%, p=0.474) mortality or postoperative morbidity. However, postoperative ICU admission (14.6% vs 7%, p=0.032), intraoperative hypotension (61.4% vs 14.6%, p<0.001), and vasopressor use (52% vs 14%, p<0.001) were more common with GA than with RA.

Conclusion

Type of anesthesia did not significantly affect mortality or morbidity after LEA. However, intraoperative hypotension, vasopressor use, and postoperative ICU admission rates were lower with RA.