Perioperative Risk, Anesthesia, Critical Care, and Readmissions

10.1Preoperative risk stratification and pathways

Preoperative assessment starts with procedural urgency, active cardiovascular disease, functional capacity and a validated estimate of perioperative risk. The 2024 AHA/ACC guideline and 2022 ESC guideline provide the contemporary framework. The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) contributes historical vascular-specific prediction evidence AHA/ACC 2024 · ESC 2022 · VSG-CRI 2010. A metabolic equivalent (MET) expresses activity intensity relative to resting metabolism. Poor functional capacity is less than 4 METs; a Duke Activity Status Index score of 34 or less is another guideline assessment threshold. A reported ability or inability to climb stairs is a screening clue, not an interchangeable objective exercise measurement. For elevated-risk surgery, stress testing may be considered when functional capacity is poor or unknown, predicted cardiovascular risk is elevated and the result would change management (AHA/ACC class IIb, B-NR). It is not routine for low-risk patients or those with adequate functional capacity. The Revised Cardiac Risk Index assesses high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes and creatinine above 2.0 mg/dL; its score informs risk assessment rather than providing universal vascular-surgery clearance.

Functional capacity should be assessed systematically. The Duke Activity Status Index is a structured patient-reported questionnaire; cardiopulmonary exercise testing measures exercise performance. Natriuretic peptide measurement assesses cardiovascular risk rather than exercise capacity itself AHA/ACC 2024. An elevated preoperative natriuretic peptide, BNP at or above 92 ng/L or NT-proBNP at or above 300 ng/L, predicts substantially increased 30-day risk of death or myocardial injury and supports intensified postoperative troponin surveillance ESC 2022 · CCS 2017.

Preoperative risk assessment and care pathways

Enhanced-recovery pathways organize nutrition, analgesia, mobilization and discharge planning but do not replace anatomic planning or selective cardiac assessment. Carotid-specific imaging and anesthesia decisions remain in the carotid chapters; the GALA trial remains historical evidence on anesthetic choice rather than a preoperative imaging protocol SVS ERAS Bypass 2023 · SVS ERAS Open Aortic 2022 · GALA (2008).

10.2Frailty and perioperative medication management

Frailty assessment precedes elective vascular intervention because it predicts complications, prolonged length of stay, readmission, and loss of independence independently of chronological age and conventional cardiac indices Frailty MA 2024 · Frailty SR 2016. In vascular surgery, frailty is associated with postdischarge mortality and structures shared decision-making rather than serving as a binary operative gate VQI Frailty 2022 · Frailty Scoping 2024.

Medication reconciliation records the indication, last dose, planned interruption and a named restart trigger. Continuing a chronic treatment is a different decision from initiating it immediately before surgery. In Stop-or-Not, withholding renin–angiotensin system inhibitors reduced intraoperative hypotension but did not reduce the 28-day composite of death or major complications Stop-or-Not 2024.

Perioperative medication management

AF below means atrial fibrillation. These elective-surgery intervals do not cover neuraxial puncture/catheter removal, urgent reversal, severe renal impairment or recent thromboembolism.

PAUSE studied elective procedures in patients with atrial fibrillation, not all anticoagulant indications; it excluded CrCl below 25 mL/min for apixaban and below 30 mL/min for dabigatran or rivaroxaban. Its overall major-bleeding rates below 2% do not describe every subgroup: rates approached 3% after high-bleeding-risk procedures in the apixaban and rivaroxaban cohorts. Absence of routine coagulation testing in that protocol does not preclude drug-specific testing when timing, renal function or urgent surgery makes residual anticoagulation uncertain PAUSE (2019).

10.3Hemodynamics, critical care, and complication tracking

Intraoperative mean arterial pressure targets are individualized to baseline chronic pressure, end-organ reserve, and procedural hemodynamics to minimize the depth and duration of hypotension Hypotension SR 2025. Avoid intraoperative MAP below 65 mmHg, and especially below 55 mmHg; the risk of myocardial injury and acute kidney injury climbs with both the depth and the cumulative duration of hypotension Salmasi 2017 · Walsh 2013. Postoperative intensive care admission is selected based on patient risk, procedural complexity, intraoperative instability, blood loss, and vasopressor requirements rather than blanket unit policies ICU Triage SR 2025.

Postoperative myocardial injury after noncardiac surgery is largely asymptomatic and carries a strong, graded association with 30-day mortality Postop Troponin MA 2020 · VISION (2017). In the VISION cohort, peak postoperative high-sensitivity troponin T elevation correlated directly with 30-day mortality: 20 to 64 ng/L yielded 3.0%, 65 to 999 ng/L yielded 9.1%, and >= 1000 ng/L yielded 29.6%, with 93.1% of patients experiencing no ischemic symptoms. Cardiac troponin T elevation above the 99th percentile occurs in approximately 16% of adults aged 45 years or older after inpatient noncardiac surgery, with nearly 90% of events lacking symptoms MINS Cohort 2018. Both ischemic and non-ischemic mechanisms contribute to long-term mortality risk MINS Mechanism 2017.

For patients with myocardial injury after noncardiac surgery, the MANAGE trial demonstrated that dabigatran 110 mg twice daily reduced major vascular complications at two years without a significant increase in major bleeding MANAGE (2018). Implementation requires weighing this benefit against specific fresh-anastomosis or procedural bleeding risks.

Access complications and bleeding

An expanding groin hematoma, unexplained hypotension, falling hemoglobin or loss of distal perfusion requires immediate reassessment of the access and reconstruction. Start resuscitation and compress a compressible puncture while obtaining vascular/endovascular assistance. Imaging must not delay hemorrhage control. Choose open repair, endovascular balloon control/covered-stent rescue, or a hybrid approach according to the injury, branch anatomy, ischemia and ability to obtain prompt hemostasis; repeated unsuccessful closure-device attempts are not a substitute for definitive control. Covered-stent series establish feasibility in selected injuries, not superiority over surgery, and common-femoral implantation may be outside device labeling Mid- Long-Term 2025. See Chapter 12, “Intervention triggers and treatment choice”, and Chapter 15, “Access complication rescue”.

Other major perioperative complications tracked in vascular populations include:

• Postoperative delirium occurs in approximately 20% of noncardiac surgery patients, driven by older age, baseline cognitive impairment, elevated inflammatory markers, and prolonged anesthetic duration Delirium IPDMA 2023.
• Postoperative atrial fibrillation develops in roughly 1% of patients without baseline disease, with preoperative N-terminal pro-brain natriuretic peptide offering independent predictive value NT-proBNP POAF 2020.
• Perioperative ischemic stroke confers elevated cardiovascular and neurologic cause-specific mortality Perioperative Stroke 2021.
• Bleeding and transfusion requirements are reduced by pharmacologic antifibrinolytics, though mortality evidence in vascular cohorts remains of low certainty Cochrane Bleeding 2023.

10.4Readmission mitigation and follow-up

Readmission after lower-extremity bypass was 18% within 30 days in the NSQIP cohort and 14% in a separate institutional cohort. In the institutional review, 75% of readmissions were related and unplanned, and wound infection accounted for 37% of indications. These are different cohorts and denominators, not a single universal rate NSQIP Readmission 2014.

Predictors of 30-day readmission following lower-extremity bypass include:

• Return to the operating room during the index admission.
• Cardiac comorbidity.
• Critical limb ischemia indication.
• Dialysis dependence.
• Malnutrition.
• Dependent functional status.
• Obesity and dyspnea NSQIP Readmission 2014.

This readmission model did not validate C-reactive protein (CRP) or procalcitonin as decision tests. Its findings therefore do not justify adding a routine laboratory cutoff for discharge or follow-up intensity. Evaluate suspected infection on its clinical merits rather than treating an isolated inflammatory-marker result as a validated readmission predictor NSQIP Readmission 2014.

For open abdominal aortic aneurysm repair, the transabdominal approach is associated with higher 30-day readmission and long-term reintervention rates compared with the retroperitoneal approach, independent of comparable perioperative mortality Transabdominal AAA 2019.

Care fragmentation and distance from the index centre complicate postoperative care Travel Distance 2023. Before discharge, identify responsibility for wound/access review, medication restart, renal monitoring when indicated, and rapid contact for bleeding, infection or recurrent ischemia. Arrange earlier review for unresolved wounds, complications, poor support or barriers to return, rather than assigning every patient an aggressive fixed schedule. Observational outpatient-follow-up data do not prove that earlier visits prevent readmission; visits may appropriately trigger necessary admission Outpatient Follow-up 2014.

Aortic imaging surveillance is a separate task from early readmission prevention. After standard infrarenal EVAR, ESVS recommends early CTA within 30 days, then follow-up stratified by seal, endoleak, anatomy and device-related risk. Selected low-risk patients can have less frequent imaging during the first five years, but long-term follow-up remains necessary. This is not an intensive-clinic schedule for every bypass or open-aortic patient ESVS 2024.

10.5Areas of controversy

The strength of evidence underlying vascular-specific Enhanced Recovery After Surgery pathways for open aortic and infrainguinal bypass operations remains moderate to weak due to a paucity of high-quality randomized trials in these populations SVS ERAS Bypass 2023 · SVS ERAS Open Aortic 2022.

While the MANAGE trial supports dabigatran therapy for patients with myocardial injury after noncardiac surgery, balancing this antithrombotic benefit against the bleeding risk of fresh vascular reconstructions, groin incisions, and retroperitoneal dissections remains center-dependent and driven by specific procedural anatomy MANAGE (2018).

The decision to withhold or continue angiotensin-converting enzyme inhibitors and angiotensin receptor blockers preoperatively lacks uniform consensus, requiring individualized trade-offs between intraoperative hypotension and baseline heart-failure stability or refractory hypertension SPACE (2024) · Stop-or-Not 2024.

Further reading

• Intensive care after vascular surgery: systematic review. (2025). Postoperative intensive-care evidence specific to vascular surgery. ICU Triage SR 2025
• Decision making in the frail vascular surgery patient: A scoping review. (2024). Frailty and vascular decision-making; scoping rather than effect-estimate synthesis. Frailty Scoping 2024