Peripheral subcutaneous AV fistula or prosthetic graft is the current procedure of choice for patients requiring permanent hemodialysis access. The procedure is performed in supine position and is usually performed under local anesthesia with intravenous sedations. Elderly patients with chronic renal failure may present a great challenge to the anesthesiologists. Conditions like congestive heart failure, systemic hypertension, electrolyte imbalances, undetermined intravascular fluid volume status are fairly common in this age group. The presence of concomitant dementia, poor baseline cognitive function may make sedation and local anesthesia inadequate choice. In such patients, consideration should be made for brachial plexus block using an ultrasound-guided supraclavicular or infraclavicular approach. In a study by Mizrak et al. [16] when used for Arteriovenous Fistula (AVF) access surgery , infraclavicular brachial plexus block provides higher blood flow in the radial artery and AVF than is achieved with infiltration anesthesia. In another study by Malinzak and Gan [17, ] it was also concluded that use of regional blocks may improve the success of vascular access procedures by producing significant vasodilatation, greater fistula blood flow, sympathectomy-like effects, and decreased maturation time. Significant vasodilation after regional block administration is seen in both the cephalic and basilic veins. These vasodilatory properties may assist with AVF site selection.

Anesthesia for peripheral arterial stent placement can be administered with intravenous moderate sedation and local anesthetic at the puncture site. A common combination for sedation is 1–2 mg of midazolam (Versed) and 25–50 mcg of fentanyl, depending on the patient’s size and response. Standard ASA monitoring with Monitored Anesthesia care is used for these procedures.

The anesthetic technique for Carotid artery stent involves minimal sedation with minimal or no midazolam as excessive sedation may contribute to hypotension in the post stent placement phase. Activated clotting time (ACT) is measured. After a baseline ACT, a small heparin bolus is administered IV to achieve an ACT of approximately twice as normal (250–300 s) to prevent thromboembolic complications. Protamine should be immediately available to treat hemorrhage, although it is not routinely used for the reversal of anticoagulation at the end of the case. Often an oral antiplatelet drug (ticlopidine, clopidogrel, or abciximab) is also given.

The anesthesiology team should also anticipate excessive bradycardia with carotid balloon angioplasty necessitating the pre-emptive use of Atropine 0.4–0.8 mg or Glycopyrollate 0.2–0.4 mg.

The lower extremity vascular procedures can be ideally performed under regional anesthesia. Regional anesthesia involves spinal, epidural anesthesia, lumbar plexus anesthesia, and regional nerve blocks involving the sciatic, femoral, popliteal fossa nerve blocks, and ankle blocks.

Vascular operations for the lower extremity constitute infrainguinal arterial bypass procedures. Use of an autogenous vein provides the best conduit for infrainguinal arterial bypass procedures. The principle is to have an inflow target that has no significant disease proximal to it that can interfere with the inflow into the bypass. The inflow vessel is usually the common femoral artery, profunda femoris artery, the superficial femoral artery, the popliteal artery, and, in some less common instances, one of the tibial vessels. The target recipient artery is either the popliteal artery or tibial, peroneal, or pedal vessel. These can be approached at the level of the knee or below with a medial incision or at mid tibial/malleolus level depending on the target. It requires administration of 10,000 units of heparin prior to distal anastomosis, followed by proximal anastomosis, arteriogram, partial reversal of heparin, and closure.

Spinal anesthesia provides excellent analgesia but since surgery can be unpredictable in complexity and duration, it may be beneficial to either perform a continuous spinal anesthesia [18, 19] with an intrathecal catheter or perform a combined spinal/epidural or just lumbar epidural catheter [20]. This allows the duration of anesthesia to be extended and may also provide postoperative analgesia. Surgical anesthesia involves L1–4 dermatomes, and a dermatomal level of T10-T12 is required. Hoff et al. [21] showed that spinal anesthesia using bupivacaine and tetracaine mixed in a single-injection technique can last 5 h at the T₁₂ level without added untoward effects when compared with lower dose spinal anesthetics. Cautious fluid administration and vasoconstrictors use will limit fluid overload in elderly patients especially after sympathectomy resolves. Strict adherence to American Society of Regional Anesthesia (ASRA) anticoagulation guidelines as mentioned in the previous section should be practiced before performing spinal anesthesia and prior to removal of the epidural catheter.

Yazigi et al. [22] showed in a series of 25 patients that infrainguinal bypass can be safely performed with combination femoral and sciatic nerve blockade without conversion to general anesthesia (GA ). They [23] further did a prospective, randomized study comparing peripheral nerve blockade with general anesthesia for infrainguinal bypass and showed a statistically significant reduction in intraoperative myocardial ischemia in the group randomized to peripheral nerve blockade. Local anesthesia [24] and a combination [25] of a psoas compartment block, sciatic nerve block, and ipsilateral T12-L1 paravertebral block has also been shown to be successful in performing lower limb vascularization surgeries.

Thus local anesthesia and regional nerve blocks can be safely used for lower extremity vascularization procedures but larger randomized trials are needed to confirm the benefits over spinal and general anesthesia. The regional nerve blocks, neuraxial anesthesia, and local anesthesia are limited in their benefits in patients with moderate to severe chronic low back pain and in elderly patients with dementia, as such patients may be difficult to sedate and may require general anesthesia to perform the surgical procedures safely.

Considerable controversy exists over benefits of regional anesthesia over general anesthesia and many institutions have established different standards of care in managing anesthetic care for patients undergoing the above procedures. The goal of the following section is to clearly state the benefits of regional anesthesia in vascular surgery and specifically to geriatric population.

The advantages of spinal and epidural anesthesia using local anesthetic and/or opioids include avoidance of airway manipulation and pulmonary morbidity, and lower blood loss, which leads to reduction of the surgical stress response [26–28]. Urinary cortisol excretion , a marker of the stress response, was significantly diminished during the first 24 postoperative hours in the group receiving epidural anesthesia in a landmark study by Yeager et al. [29]. Reduction of surgical stress response leads to stable hemodynamics, reduced hypercoagulability, better wound healing, and less immunosuppression.

Further, vasodilation, secondary to sympathetic blockade, should be particularly helpful in sustaining graft patency.

In the Perioperative Ischemia Randomized Anesthesia Trial (PIRAT) [30], 100 patients were randomized to undergo lower extremity grafts under either epidural or general anesthesia found that revascularization rate was high in the GA group. Rosenfeld et al. [31], using patients from the PIRAT study , reported an increase in plasminogen activator inhibitor (PAI-1) in the general anesthesia patients but not in the regional anesthesia patients on the morning after surgery (Fig. 3.2).

A review of retrospective, prospective, and meta-analysis studies by Moraca et al. [32] showed significant reduction in perioperative cardiac morbidity (30%), pulmonary infections (40%), pulmonary embolism (50%), ileus (2 days), acute renal failure (30%), and blood loss (30%). Potential complications related to epidural anesthesia/analgesia ranged from minor issues like transient paresthesias (10%) to rare potentially devastating epidural hematomas (0.0006%).

Thoracic epidural analgesia can enhance bowel motility not only by producing pain relief and lessening the systemic stress response, but also by creating a sympathectomy, resulting in unopposed parasympathetic innervations to the gut. Sympathetic stimulation, pain, opioids, nitrous oxide, inhalation anesthetics, and increased endogenous catecholamines all contribute to postoperative ileus, and all are blunted in patients treated with perioperative thoracic epidural analgesia [33].

Chery et al. [34] showed in a retrospective review of 407 consecutive patients who underwent above- or below-knee amputations at a single center. The study showed that regional anesthesia group which has older patients (76.6 vs.71.6) was associated with a lower incidence of overall postoperative pulmonary complications and postoperative arrhythmia. Duration of stay in the intensive care unit and hospital was significantly longer in the group receiving general anesthesia. No significant differences in postoperative myocardial infarction, venous thromboembolism, or mortality were seen between groups. Regional anesthesia included either spinal or combined spinal and epidural anesthesia. Nerve blocks were not used.

Singh et al. [35] did an analysis of a prospectively collected database by the National Surgical Quality Improvement Program (NSQIP) of the Veterans Affairs Medical Centers of all patients from 1995 to 2003 in the NSQIP database who underwent infrainguinal arterial bypass. Their results revealed that compared with general endotracheal tube anesthesia, spinal anesthesia (SA) was associated with superior 30-day graft patency, fewer cardiac events in patients without congestive heart failure but with normal functional status, less postoperative pneumonia, and decreased odds of returning to the operating room. In contrast, SA was significantly better than epidural anesthesia only in the incidence of return to the OR. There was no significant difference in 30-day mortality among the three groups with univariate or multivariate analyses.

The use of neuraxial regional anesthesia (epidural) has shown to decrease incidence of elevated intraoperative blood pressure and variability in heart rate and blood pressure when compared to general anesthesia [36].

However, later Ghanami et al. [37] did observational analysis of 5642 patients to evaluate the effects of regional versus general anesthesia for infrainguinal bypass. The study showed no evidence to support the systematic avoidance of general anesthesia for lower extremity bypass procedures. In particular, graft thrombosis was found in 7.3% of patients, with an equal rate in both groups. Pulmonary morbidity occurred in 4% of patients and the rate of cardiovascular complications was 2.8% of general anesthesia patients and 2.2% of regional anesthesia patients. Venous thromboembolism rates were similar. These data suggest that anesthetic choice should be governed by local expertise and practice patterns.

Although neuraxial techniques confer some protection in the reduction in the rate of thromboprophylaxis as eluded in the PIRAT trial and large study by Singh et al., anticoagulant therapy has a major role in the in the maintenance of vascular graft patency in the perioperative period. Since anticoagulation has an important role in the decision making for neuraxial anesthesia, it is important to review the 2010 American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) on regional anesthesia in patient receiving anticoagulant therapy and compare them with the latest guidelines published in Regional Anesthesia Pain Medicine 2015 [38]:

Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancelation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case is warranted.

Although regional anesthesia (spinal and epidural anesthesia ) has desirable effects, there is no sufficient data to recommend regional anesthesia over general anesthesia. With the advent of new anesthetic agents, general anesthesia can be safely used with attention to detail throughout the perioperative period and aggressive management of hemodynamic changes.

It is clearly evident that severe pain after amputation is clearly associated with a higher prevalence of post-amputation pain [39, 40]. While there are numerous studies available showing decrease in incidence of phantom limb pain (PLP) [41, 42] with perioperative epidural analgesia, there are studies [43] which refute this observation. In a recent study by Karanikolas et al. [44, ] optimized epidural analgesia or intravenous PCA, starting 48 h preoperatively and continuing for 48 h postoperatively, decreases PLP at 6 months.

Patients undergoing peripheral and major vascular surgery constitute a particular challenge, as these patients have high prevalence of significant coronary artery disease. The usual symptomatic presentation for coronary artery disease in geriatric patients with vascular disease may be obscured by exercise limitations imposed by advanced age, intermittent claudication, or both. Perioperative hemodynamic changes like increases in blood pressure and heart rate, elevated preload, increased contractility, hypotension, tachycardia, anemia, and hypoxemia can predispose to myocardial ischemia, which is more pronounced in patients with underlying coronary disease.

The current standards for preoperative cardiac evaluation of these patients are the guidelines published by the American College of Cardiology (ACC) and these were revised in 2007 [45] and again in 2014 [46].

The 2007 Guidelines defined cardiac risk as combined incidence of cardiac death and nonfatal myocardial infarction and stratified it into low, intermediate (including carotid endarterectomy), and high risk (surgery for peripheral vascular diseases , aortic and other major vascular surgeries). In the absence of active cardiac conditions in a patient undergoing low-risk surgery, there was no indication for any further testing. The 2007 guidelines recommended that in patients undergoing intermediate risk or vascular surgery procedure, the presence of clinical risk factors determine further approach if their functional capacity was unknown or less than 4METS. Further invasive testing in patients undergoing vascular surgery should be considered only if it will change management.

The 2014 ACC guideline states that because recommendations for intermediate- and high-risk procedures are similar, classification into two categories, namely, low and elevated risk, simplifies the recommendations without loss of fidelity. A low-risk procedure is one in which the combined surgical and patient characteristics predict a risk of a major adverse cardiac event (MACE) of death or myocardial infarction (MI) of <1%. The lowest-risk operations are generally those without significant fluid shifts and stress. Plastic surgery and cataract surgery are associated with a very low risk of MACE. Procedures with a risk of MACE of >1% are considered elevated risk. Operations for peripheral vascular disease and aortic surgeries are generally performed among those with the highest perioperative risk. Some operations can have their risk lowered by taking a less invasive approach. For example, open aortic aneurysm repair has a high risk of MACE that is lowered when the procedure is performed endovascularly. In addition, performing an operation in an emergency situation is understood to increase risk.

A risk calculator has been developed that allows more precise calculation of surgical risk, which can be incorporated into perioperative decision making. The three most commonly used tools to calculate MACE risk are Revised Cardiac Risk Index (RCRI) , American College of Surgeons National Surgical Quality Improvement Program (NSQIP) , Myocardial Infarction and Cardiac Arrest (MICA) , and American College of Surgeons NSQIP Surgical Risk Calculator .

The RCRI is a simple, validated, and accepted tool to assess perioperative risk of major cardiac complications (MI, pulmonary edema, ventricular fibrillation or primary cardiac arrest, and complete heart block). It has six predictors of risk for major cardiac complications, only one of which is based on the procedure—namely, “Undergoing suprainguinal vascular, intraperitoneal, or intra thoracic surgery”. A patient with zero or one predictor(s) of risk would have a low risk of MACE. Patients with >2 predictors of risk would have an elevated risk for adverse major cardiac events (MACE).

In a nutshell, 2014 ACC guidelines recommend that in a patient with known clinical risk factors for CAD scheduled for nonemergent elevated risk surgery (MACE > 1) and with poo r(<4METS) or unknown functional capacity, further pharmacological cardiac testing should be ordered if it will impact decision making or perioperative care. This follows a similar theme as 2007 guidelines.

It is also very important to note that implementation of the American College of Cardiology/American Heart Association guidelines has been associated with better perioperative outcomes.

Preoperative testing should not be determined by patient age alone [47]. Clinical yield of undirected or “routine” preoperative testing protocols is extremely low [48, 49]. Undirected or routine preoperative chest radiographs are unnecessary in elderly surgical patients.

Since older surgical patients are slightly more likely to be anemic, a complete blood count is mandatory for all vascular surgeries.

The prothrombin time (PT) and partial thromboplastin time (PTT) appear to have no value as screening tests in asymptomatic patients of any age with no evidence of liver disease and not taking anticoagulants. However, since most vascular surgery patients are on anticoagulants, a baseline measure of PT/PTT is required especially if planning spinal or epidural anesthesia.

Since many elderly patients may have concomitant renal dysfunction and diastolic dysfunction, a basic blood chemistry is prudent in the management of intraoperative fluid therapy.

ECG appears to be sufficiently cost-effective to warrant routine application in a geriatric population [50]. As per ACC guidelines of 2014, routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures. Since EG carries baseline information and is a prognostic standard, it is reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease. There is poor concordance across different observational studies as to which abnormalities have prognostic significance including arrhythmias, pathological Q-waves, LV hypertrophy, ST depressions, QTc interval prolongation, and bundle-branch blocks. Likewise, the optimal time interval between obtaining a 12-lead ECG and elective surgery is unknown. General consensus suggests that an interval of 1–3 months is adequate for stable patients.

As per AHA guidelines it is reasonable to get an ECHO in the following patients:

Exercise testing for ischemia may be considered (Class IIb) for patients with elevated risk and unknown or poor (<4METS) functional capacity if it will change management. However, it is to be noted that vascular surgery patients may not be able to do exercise testing due to concomitant claudication. Patients able to achieve approximately 7 METs to 10 METs have a low risk of perioperative cardiovascular events, and those achieving <4 METs to 5 METs have an increased risk of perioperative cardiovascular events. Electrocardiographic changes with exercise are not as predictive.

Noninvasive pharmacological testing may be reasonable (Class IIa) for patients at elevated risk and have poor (<4 METs) functional capacity to undergo noninvasive pharmacological stress testing (either dobutamine stress echocardiogram (DSE) or pharmacological stress (MPI) if it will change management (Level of Evidence: B) The authors identified a slight superiority of stress echocardiography relative to nongated MPI with thallium in predicting postoperative cardiac events. In patients with abnormalities on their resting ECG for example: left bundle-branch block, LV hypertrophy with “strain” pattern, digitalis effect, concomitant stress imaging with echocardiography or MPI may be an appropriate alternative.

As per AHA guidelines consistent and clear associations exist between beta blocker administration and adverse outcomes, such as bradycardia and stroke. Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically. In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification test for instance three or more RCRI risk factors (e.g., diabetes mellitus, HF, CAD, renal insufficiency, and cerebrovascular accident), it may be reasonable to begin perioperative beta blockers 2–7 days before surgery. They recommend against starting beta blockers on the day of surgery in beta–blocker-naïve patients.

Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery and statins should be continued in patients currently taking them.

The risk of coronary stent thrombosis in the perioperative period for both bare metal stent (BMS) and drug-eluting stent (DES) is highest in the first 4–6 weeks after stent implantation. Discontinuation of dual antiplatelet therapy (DAPT) , particularly in this early period, is a strong risk factor for stent thrombosis. In patients undergoing urgent noncardiac surgery during the first 4–6 weeks after BMS or DES implantation, DAPT should be continued unless the relative risk of bleeding outweighs the benefit of the prevention of stent thrombosis. As such, use of DAPT or aspirin alone should be individualized on the basis of the considered potential benefits and risks. All elective surgeries should be delayed for minimum 30 days for BMS and 365 days for DES.

Pharmacokinetic implies the relationship between drug dose and plasma concentration Pharmacodynamics implies the relationship between plasma concentration and clinical effect.

In older patients subtle changes in pharmacodynamics and altered age-related alpha phase redistribution pharmacokinetics are responsible for varied drug effect.

With aging [1], lean body mass decreases [2], body fat increases [3], and total body water decreases.

The reduced volume of distribution for water-soluble drugs can lead to greater plasma concentrations after rapid bolus or infusions. Conversely, an increased volume of distribution (due to increase in body fat) for lipid-soluble drugs could reduce their plasma concentration but lead to larger volume of distribution after prolonged infusions leading to increased drug effect. It is interesting to note that the decreased dose requirement of fentanyl in the elderly has a pharmacodynamic explanation, that is, elderly brain is more sensitive to opioids [51].Thus pharmacodynamics basis, increased brain sensitivity explains decreased minimum alveolar concentration (MAC) of volatile anesthetics [52, 53], decreased dosing requirement of opioids [54] and benzodiazepines [55].

The prolonged duration of action of vecuronium [56] and rocuronium [57] in the elderly surgical patients is related to altered pharmacokinetics consistent with an age-related decrease in renal and hepatic functions. Recovery from pancuronium that depends on renal excretion may be delayed due to decreased drug clearance. Hofmann elimination, an organ-independent elimination pathway, occurs in plasma and tissue, and is responsible for approximately 77% of the overall elimination of cisatracurium besilate. Therefore, it provides most consistent clinical effects in the elderly. Proper neuromuscular monitoring with meticulous attention to train of four and reversal of neuromuscular blockade along with adherence to clinical criteria for extubation must be met prior to extubation of elderly patients. Complete recovery of neuromuscular function is more likely when anticholinesterases are administered early (>15–20 min before tracheal extubation) and at a shallower depth of block (train-of-four [TOF] count, 4) [58].

In a large US Veterans Affairs screening study , the prevalence of abdominal aortic aneurysm (AAA) was 1.4% [59].

Abdominal aortic aneurysms were the primary cause of 10,597 deaths and a contributing cause in more than 17,215 deaths in the United States in 2009 [60]. AAA repair involves the replacement or bypass of an aneurysmal section of abdominal aorta. There are two primary methods of AAA repair , open repair and endovascular repair (EVAR) . Open AAA repair is well established as a definitive treatment, having been in use for over 50 years. Generally, EVAR is advocated for patients who are at increased risk with open repair.