Anaesthesia and vascular surgery in the elderly

Abstract

Elderly patients undergoing vascular surgery have a high incidence of ischaemic heart disease, respiratory disease, hypertension and diabetes mellitus and a general reduction in physiological reserve. Assessment is complicated by reduced mobility and silent coronary artery disease. Meticulous preparation and careful management of anaesthesia are essential, with emphasis on cardiovascular stability, fluid balance, control of pain, maintenance of body temperature and appropriate use of intensive care facilities. Regional anaesthesia and analgesia may be helpful, promoting haemodynamic stability, early extubation and reduced respiratory complications in aortic surgery and, in peripheral vascular surgery, reducing the incidence of graft failure. Aortic clamping and unclamping require special attention and may precipitate cardiac decompensation. Invasive intravascular monitoring is required for aortic surgery and, in selected patients, for carotid endarterectomy or peripheral vascular reconstruction. Assessment of the adequacy of cerebral blood flow may be required during carotid surgery to indicate the need for shunt insertion. Patients usually present for vascular surgery because of atherosclerotic occlusive disease (peripheral vascular reconstruction, aortoiliac bypass and carotid endarterectomy) or aneurysmal disease (principally of the abdominal aorta). Both are conditions of later life and are often associated with other conditions, especially ischaemic heart disease, chronic respiratory disease, hypertension and diabetes mellitus. Assessment of these patients is particularly challenging because of limited exercise tolerance and mobility. Furthermore, the perioperative management may be problematic because of the interaction of haemodynamic and surgical stress, the effects of anaesthesia, underlying ischaemic heart disease and the reduced physiological reserve of the elderly patient.