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Patients having anaesthesia for vascular surgery are often high risk patients with severe atherosclerosis. Atherosclerosis is a hardening and thickening of the arteries which eventually leads to a loss of blood supply to the organ which that artery supplies. If the coronary arteries are affected patients may have angina or present with a heart attack. If the carotid arteries in the neck are affected patients present with minor or major strokes. Atherosclerosis which affects the femoral or popliteal arteries (those which supply the legs) may result in gangrene of the affected limbs. The arteries involved determine the type of operation.

Three common vascular operations are:

• Carotid Endarterectomy
• Abdominal Aortic Aneurysm
• Femoral Popliteal Bypass

CAROTID ENDARTERECTOMY

Your surgeon may recommend this operation if you have had a recent minor stroke or a blockage may have been detected by your general practioner. The carotid arteries arise in the neck. There are four main arteries which supply the brain. Two vertebral and two carotid arteries. A blockage in the carotid arteries may lead to stroke. The aim of surgery is to remove the atherosclerotic plaque which obstructs the great vessels of the neck before a major stroke occurs. Unfortunately, atheroscerotic disease is not confined to the carotid arteries and may affect other arteries in the body including the heart.

Pre-operatively you will be seen by your anaesthetist who will assess your overall health and suitability for surgery. The pre-operative assessment allows the anaesthetist to assess your physical condition and gives you the opportunity to discuss any concerns which you may have. You will be asked to fast from midnight. Most medications can be taken when due with a small sip of water. Pre-meds are not given unless necessary. Any pathology tests required are arranged before surgery.

On the morning of surgery an arterial line (a needle to monitor your blood pressure directly) and wide-bore I.V. cannula is inserted under local anaesthesia. The procedure itself is done under a general anaesthetic. A breathing tube is inserted whilst you are asleep. The aim of surgery is to restore blood supply to the brain and prevent stroke. The critical times during the operation are during clamping of the carotid artery to allow surgery. If the back pressure is inadequate at the time of clamping a temporary shunt may be required.

At the conclusion of the procedure you will be woken up and asked to perform some simple tasks to assess your neurological function. After a brief period of time in the recovery you will be transferred to intensive care unit for monitoring. Expect 24 hours in intensive care before transfer to your own ward.

SURGERY FOR ABOMINAL AORTIC ANEURYSMS

This is high risk surgery on the aorta which supplies most of the blood to your lower abdomen and limbs. About 95% of all Aortic aneurysms (known as AAA’s or “triple A’s”) occur below the renal (kidney) arteries. The annual risk of rupture of an expanding 5 cm aneurysm is 4%. If the aneurysm ruptures the risk of death is 70-80%. If repaired electively the risk of death is approximately 5%.

Patients presenting for aortic aneurysm surgery are admitted to hospital prior to the day of surgery and assessed by their anaesthetist. Pathology tests, electrocardiogram and cross-matched blood is arranged. If more specialized test are requires these will be arranged pre-operatively. Because of the risk associated with this procedure your surgeon, anaesthetist and theatre staff work as a team to give you the best chance of a successful outcome.

Patients are fasted from midnight. Usual medications are continued on the morning of surgery with small sips of water. A wide bore intravenous cannula, central venous line (inserted into the internal jugular vein) and an arterial line will be inserted by your anaesthetist under local anaesthesia prior to the patient going to sleep. An epidural may also be inserted at this point. The advantages and disadvantages of using an epidural during this procedure will be discussed with you at the time of the pre-anaesthetic assessment.

Patients having AAA surgery will require a full (general) anaesthetic. The operation can take about 4-6 hours. The depth of anaesthesia is controlled by the use of narcotics and anaesthetic gases. Blood transfusions are frequently required. Medications such as adrenalin may be required to control and support the heart. If the clamp is above the renal arteries then further medications are used to protect the kidney during cross clamping. At the end of the procedure expect to be transferred to the intensive care unit. You may or may not require further ventilatory support of your breathing at this stage. This often depends on the amount of blood loss, body temperature and your pre-existing medical conditions.

FEMORAL POPLITEAL BYPASS SURGERY

Patients presenting for this operation have had a history of worsening leg pain (claudication pain) especially with exercise. The cause of the pain is often decreased blood supply to the limbs as a result of atherosclerosis. Atherosclerosis is a hardening or thickening of the arteries which often affects other major blood vessels in the body. Often patients have had other evidence of atherosclerosis which includes strokes or Transient Ischaemic Attacks (T.I.A’s) or angina and heart attacks.

Patients presenting for this operation are assessed by their anaesthetist prior to surgery. The role of the pre-operative assessment is for the anaesthetist to assess your suitability for surgery and to familiarize him/herself with any co-existing conditions which you may have. Any questions or concerns which you may have may be discussed at this time.

Patients are required to fast from midnight. Usual medications can be taken when due with small sips of water. There are two main ways to anaesthetize patients for this procedure which are general and regional (spinal or epidural) anaesthesia.

Neither technique is necessarily superior to the other and the choice will be made by the anaesthetist depending on the patients pre-existing conditions and patients wishes. Risk vs benefit of each approach are discussed with you at the time of the pre-op visit. You can expect surgery to last for 2-3 hours.

During this time your anaesthetist will control your respiration, pulse, blood pressure, temperature and depth of anaesthesia.. Blood transfusions are occasionally required. Depending on your condition transfer to intensive care may be required post operatively.

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