Optimizing Preoperative Evaluation for the Vascular Surgery Patient: A Structured Approach
Shirin Saeed, MD, Sumeeta Kapoor, MD, Xiaohan Xu, MD
Published July 3, 2024 | Clinics in Medical Education
Issue 7 | Volume 1 | June 2025
Vascular surgery patients present a complex clinical challenge due to the interplay of procedural risk and extensive patient comorbidities. Despite the shift toward endovascular techniques that lower procedural risk, these patients often carry a high systemic burden commonly due to comorbidities including hypertension, diabetes, hyperlipidemia, renal impairment, and cardiovascular disease. This evolving surgical landscape necessitates a nuanced preoperative evaluation strategy to reduce perioperative morbidity and mortality.
A dual-axis approach categorizing risk by both procedure and patient factors is essential for perioperative risk assessment. Procedures such as EVAR, peripheral stenting, and carotid interventions are generally considered intermediate-risk. However, high-risk patients undergoing even these procedures require meticulous assessment. Key to this evaluation is a structured cardiac risk assessment informed by tools like the Revised Cardiac Risk Index (RCRI) and the National Surgical Quality Improvement Program (NSQIP) calculator, functional capacity (via DASI or METs), and the identification of frailty, particularly in patients over 65. Patients with a MET score of less than 4 should be considered high risk.
Routine testing protocols include obtaining a 12-lead ECG within three months of surgery or with new symptoms, bedside transthoracic echocardiography (TTE) for all patients, and stress testing reserved for those with poor functional capacity and symptoms suggestive of active cardiac conditions. Cardiac biomarkers, such as cTnI and NT-proBNP, and CT angiography may be considered on a case-by-case basis. (Table 1) Renal risk is another critical factor, given the prevalence of chronic kidney disease in this population and the frequent use of contrast. Preoperative renal function, hematologic parameters, and electrolyte levels should be assessed especially for endovascular procedures.
In conclusion, comprehensive and patient-specific preoperative evaluation using structured tools and institutional best practices is essential to improving outcomes in vascular surgery patients. Integrating multidisciplinary input, particularly for those at high cardiac or renal risk, ensures safe perioperative management in this vulnerable population.
