Preoperative Evaluation and Clinical Risk Assessment

Description

History

●Age

●Gender

●Functional capacity

●Past medical and surgical history

●Present and past medication use

●Smoking status

●Allergies

●Alcohol misuse

●Illicit drug use

●History of trauma

●Family history of aneurysm or dissection

●Marfan’s syndrome

●Connective tissue disorders

●Aortic dissection

●Others

Physical examination

●Vital signs

●Carotid bruit

●Heart sounds and murmur

●Lung fields and sounds

●Abdominal examination

●Pulse examination

Laboratory studies

●Complete blood count

●Blood urea nitrogen (BUN) and serum creatinine (Cr)

●Serum electrolyte values

●Blood glucose

●Prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR)

Resting 12-lead ECG

Ankle-brachial index test

Imaging studies

●Chest radiograph

●Computed tomographic angiography (CTA) chest, abdomen, and pelvis

Informed consent

Table 10.2

Estimated energy required for various activities (functional capacity)^a

Functional capacity	Examples of activity
Excellent (>10 METs)	Strenuous sports such as football, basketball, singles tennis, karate, jogging 10 min mile or greater, chopping wood
Good (7–10 METs)	Doubles tennis, calisthenics without weights, golfing without cart
Moderate (4–6 METs)	Climbing a flight of stairs or walking up a hill, running a short distance, heavy housework (scrubbing floors or moving furniture)
Poor (1–3 METs)	Eating, walking at 2–3 miles per hour, getting dressed, light housework (washing dishes)

MET metabolic equivalent unit

^aReprinted from Journal of Vascular Surgery, 50 (4 Suppl), Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al., The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines, S2–49, Copyright 2009, with permission from Elsevier

In addition to laboratory studies listed in Table 10.1, disease-specific laboratory studies should be considered in select patients such as those with Marfan’s syndrome , connective tissue disorders, infection, or rheumatologic disorders. An overall assessment of health can be quantified using two modalities:

American Society of Anesthesiology (ASA) Physical Status Classification [21]

This classification (Table 10.3) is simple and universal for risk stratification for all patients undergoing surgery, but it may have inter-rater reliability even among anesthesiologists [22, 23].

Table 10.3

American Society of Anesthesiologists’ (ASA) physical status classification^a

Class	Description	Examples (including, but not limited to)
I	A normal healthy patient	Healthy, nonsmoking, no or minimal alcohol use
II	A patient with mild systemic disease; no functional limitation	Current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM or HTN, mild lung disease
III	Severe systemic disease ; definite functional limitation	One or more moderate-to-severe diseases: poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥ 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA <60 weeks, history of MI (>3 months), CVA, TIA, or CAD/stents
IV	Severe systemic disease that is constant threat to life	Recent MI (<3 months), CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD, or ESRD not undergoing regularly scheduled dialysis
V	Moribund patient; unlikely to survive 24 h with or without operation	Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

The addition of “E” denotes emergency surgery

ARD acute respiratory distress, BMI body mass index, CAD coronary artery disease, COPD chronic obstructive pulmonary disease, CVA cerebrovascular accident, DIC disseminated intravascular coagulation, DM diabetes mellitus, ESRD end-stage renal disease, HTN hypertension, MI myocardial infarction, PCA postconceptional age, TIA transient ischemic attack

^aReproduced with permission from the American Society of Anesthesiologists. ASA physical status classification system. 2014 [cited 2015 August 6]; Available from: http://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system

Society for Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) Comorbidity Score [24]

In this scoring model, cardiac, pulmonary, and renal risk factors are considered major components, whereas hypertension and age are used as minor components (Table 10.4). The results of established screening tests, such as the dipyridamole thallium perfusion scan and ejection fraction are included as well. A combined comorbidity severity score is calculated based on risks in both early and late mortality after open or endovascular procedure, with a highest weighting for cardiac risk , which accommodates to the prevalence of cardiac comorbidities in patients with vascular disease (Table 10.5). Scores can be divided by 10 to yield a comorbidity severity score on a 3-point scale, where grades of 0–3 correspond to absent, mild, moderate, and severe. The SVS reporting standards also propose an anatomical risk classification system which is beyond the scope of this chapter [24].

Table 10.4

SVS/AAVS medical comorbidity grading system^a

Score	Description
Major components
Cardiac status
0	Asymptomatic, with normal electrocardiogram
1	Asymptomatic but with either remote myocardial infarction by history (6 months), occult myocardial infarction by electrocardiogram, or fixed defect on dipyridamole thallium or similar scan
2	Any one of the following: stable angina, no angina but significant reversible perfusion defect on dipyridamole thallium scan, significant silent ischemia (1 % of time) on Holter monitoring, ejection fraction 25–45 %, controlled ectopy or asymptomatic arrhythmia, or history of congestive heart failure that is now well compensated
3	Any one of the following: unstable angina, symptomatic or poorly controlled ectopy/arrhythmia (chronic/recurrent), poorly compensated or recurrent congestive heart failure, ejection fraction less than 25 %, myocardial infarction within 6 months
Pulmonary status
0	Asymptomatic, normal chest radiograph, pulmonary function tests within 20 % of predicted
1	Asymptomatic or mild dyspnea on exertion, mild chronic parenchymal radiograph changes, pulmonary function tests 65–80 % of predicted
2	Between 1 and 3
3	Vital capacity less than 1.85 L, FEV₁ less than 1.2 L or less than 35 % of predicted, maximal voluntary ventilation less than 50 % of predicted, PCO₂ greater than 45 mmHg, supplemental oxygen use medically necessary, or pulmonary hypertension
Renal status
0	No known renal disease , normal serum creatinine level
1	Moderately elevated creatinine level, ≤2.4 mg/dL
2	Creatinine level, 2.5–5.9 mg/dL
3	Creatinine level ≥6.0 mg/dL, or on dialysis or with kidney transplant
Minor components
Hypertension
0	None (diastolic pressure <90 mmHg)
1	Controlled (diastolic pressure <90 mmHg) with single drug
2	Controlled with two drugs
3	Requires more than two drugs or is uncontrolled
Age
0	<55 years
1	55–69 years
2	70–79 years
3	≥80 years

SVS/ AAVS Society for Vascular Surgery/American Association for Vascular Surgery

^aReprinted from Journal of Vascular Surgery, 35(5), Chaikof EL, Fillinger MF, Matsumura JS, Rutherford RB, White GH, Blankensteijn JD, et al., Identifying and grading factors that modify the outcome of endovascular aortic aneurysm repair, 1061–6, Copyright 2002, with permission from Elsevier

Table 10.5

Combined medical comorbidity severity scoring scheme^a

Risk factor	Weighting	Score
Cardiac	×4	12
Pulmonary	×2	6
Renal	×2	6
Hypertension	×1	3
Age	×1	3
Maximum score		30

Cardiac Risk Assessment

Cardiac deaths, related primarily to coronary artery disease (CAD) , are the dominant cause of early and late mortality after open and endovascular repair of aortic aneurysms [25–27]. Recent systematic review showed that the prevalence of AAA among patients who had coronary angiography and coronary artery bypass grafting was 9.5 % for men and 0.35 % for women [28], reaching 14.4 % among men with three-vessel disease [29]. Thus preoperative cardiac risk evaluation may indicate undiagnosed heart disease and decrease the risk of perioperative cardiac complications and death. This is especially important in the patient with complex aortic disease who necessitates extensive aortic reconstructions.

Active Cardiac Conditions

Active cardiac conditions indicate major clinical risk. These patients who have one or more active cardiac conditions generally will need intensive management, which typically results in delay or cancellation of procedure unless the procedure is emergent (Table 10.6) [30, 31].

Table 10.6

Active cardiac conditions requiring evaluation and treatment before endovascular procedure^a

	Description
Unstable coronary syndromes	●Angina symptoms with everyday living activities or inability to perform any activity without angina or angina at rest
Unstable coronary syndromes	●Myocardial infarction within 30 days
Decompensated heart failure	●New York Heart Association functional class IV
	–Unable to carry on any physical activity without discomfort
	–Symptoms of heart failure at rest
	–If any physical activity is undertaken, discomfort increases
	●Worsening heart failure
	●New-onset heart failure
Significant arrhythmias	●High-grade atrioventricular block
	●Mobitz II atrioventricular block
	●Third-degree atrioventricular heart block
	●Symptomatic ventricular arrhythmias
	●Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR >100 bpm at rest)
	●Symptomatic bradycardia
	●Newly recognized ventricular tachycardia
Severe valvular disease	●Severe aortic stenosis
	–Symptomatic (exertional dyspnea or decreased exercise tolerance, exertional angina, exertional syncope or presyncope, heart failure, angina, syncope or presyncope)
	–Mean pressure gradient >40 mmHg
	–Aortic valve area <1.0 cm²
	–Maximum aortic velocity >4.0 m/s
	●Symptomatic mitral stenosis
	–Decreased exercise tolerance
	–Exertional dyspnea

^aAdapted from Fleisher et al., ACCF/AHA [30] and Nishimura et al., AHA/ACC [31] practice guidelines

Recommendations on Perioperative Cardiovascular Assessment

Guidelines regarding evaluation and management of cardiac risk in patients undergoing intermediate- and high-risk noncardiac surgery have been reported by the 2009 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) , 2014 ACC/AHA and 2014 ESC/ESA [15, 30, 32]. The recommendations for preoperative cardiovascular assessment prior to endovascular procedures are summarized in Table 10.7. Different recommendations in the guidelines are also provided for patients who had prior percutaneous coronary interventions (Table 10.8) or coronary artery bypass grafts (Table 10.9). Supplemental tests prior to endovascular repair are also recommended in Table 10.10. It is important to highlight that the guidelines recommendations have been established prior to widespread use of more complex endovascular techniques such as branched TAAA repair, and that the level of complexity and rates of cardiac events are significantly higher with these procedures compared to standard EVAR. Therefore, one should use caution when generalizing the recommendations of suggested guidelines to more complex procedures. In our practice, we regard complex endovascular repair with similar risk as a major open aortic reconstruction [15, 30, 32].

Table 10.7

Recommendations for perioperative cardiac assessment before endovascular procedure^a

Scenario	Recommendations	COR	LOE
Patients who need emergency procedure	Proceed to the operating room, continue perioperative surveillance, postoperative risk stratification, and risk factor management	I	C
Patients with active cardiac conditions	Evaluated and treated according to guideline-directed medical therapy, elective procedure should be postponed or cancelled	I	B
Patients with poor (<4 METs) or unknown functional capacity and no clinical risk factors^b	Proceed with planned procedure	I	B
Patients with functional capacity ≥4 METs without symptoms	Proceed with planned procedure	IIa	B
Patients with poor (<4 METs) or unknown functional capacity and ≥3 clinical risk factors^b who are scheduled for endovascular procedure	Proceed with planned surgery with heart rate control	IIa	B
Patients with poor (<4 METs) or unknown functional capacity and ≥3 clinical risk factors^b who are scheduled for vascular surgery	Consider further testing if it will change management	IIa	B
Patients with poor (<4 METs) or unknown functional capacity and 1–2 clinical risk factors^b who are scheduled for vascular or endovascular surgery	Proceed with planned surgery with heart rate control	IIa	B
Patients with poor (<4 METs) or unknown functional capacity and ≥3 clinical risk factors^b who are scheduled for endovascular procedure	Consider noninvasive testing if it will change management	IIb	B
Patients with poor (<4 METs) or unknown functional capacity and 1 or 2 clinical risk factors^b who are scheduled for vascular or endovascular surgery	Consider noninvasive testing if it will change management	IIb	B

Class I recommendations suggest that procedures/treatments should be performed/administered; Class IIa recommendations suggest that it is reasonable to perform the procedure/treatment; Class IIb recommendations imply that the procedure/treatment may be considered; and in Class III the procedure/treatment should not be performed because it may not be helpful or there is no proven benefit, and may potentially be harmful to the patient

Level of evidence: A data derived from multiple randomized clinical trials or meta-analyses; B data derived from a single randomized clinical trial or nonrandomized studies; C only consensus opinion of experts, case studies, or standard of care

COR class of recommendations, LOE level of evidence, MET metabolic equivalents

^aAdapted from Fleisher et al., ACCF/AHA [30] and ACC/AHA [15] practice guidelines

^bHistory of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency (creatinine > 2 mg/dL)

Table 10.8

ACC/AHA recommendations on timing of elective noncardiac surgery in patients with previous percutaneous coronary intervention (PCI) ^a

Recommendations	COR	LOE
Endovascular procedure without angiographic evaluation is not recommended in asymptomatic patients who have undergone CABG in the past 6 years, except for high-risk patients	I	B
Endovascular procedure should be delayed 30 days after BMS implantation	I	B
Endovascular procedure should be performed at a minimum of 4 weeks and ideally 3 months after BMS implantation	IIa	B
Endovascular procedure should be delayed 14 days after balloon angioplasty^b	I	C
Endovascular procedure should optimally be delayed 365 days after DES implantation^b	I	B
A consensus decision as to the relative risks of discontinuation or continuation of antiplatelet therapy can be useful	IIa	C
Elective endovascular procedure after DES implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis	IIb	B

BMS bare-metal stent, DAPT dual-antiplatelet therapy, DES drug-eluting stent, PCI percutaneous coronary intervention

^aAdapted from Fleisher et al., ACC/AHA practice guidelines [15] and Kristensen et al. ESC/ESA guidelines [32]

^bClass IIa recommendation and B level of evidence in 2014 ESC/ESA guidelines

Table 10.9

Recommendations for supplemental testing before endovascular procedure^a

Testing	Scenario	Recommendations	COR	LOE
Resting 12-lead ECG	Patients who have risk factor(s) and are scheduled for intermediate- or high-risk surgery	Recommended	I	C
	Patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease	Reasonable	IIa	B
	Asymptomatic patients without known coronary heart disease	May be considered	IIb	B
	Patients with no risk factors and age >65 years who are scheduled for endovascular procedure	May be considered	IIb	C
Assessment of LV function	Patients with dyspnea of unknown origin to undergo preoperative	Reasonable	IIa	C
	Patients with HF with worsening dyspnea or other change in clinical status	Reasonable	IIa	C
	Clinically stable patients	Reassessment of LV function may be considered if there has been no assessment within a year	IIb	C
		Routine preoperative evaluation of LV function is not recommended	III: No Benefit	B
Stress testing
Exercise stress testing	Patients with elevated risk and excellent (>10 METs) functional capacity	Reasonable to forgo and proceed to endovascular procedure	IIa	B
	Patients with elevated risk and unknown functional capacity	May be reasonable if it will change management	IIb	B
	Patients undergoing elevated risk procedures and unknown functional capacity	May be considered	IIb	B
	Patients with elevated risk and moderate-to-good (≥4 METs to 10 METs) functional capacity	May be reasonable to forgo and proceed to endovascular procedure	IIb	B
	Patients with elevated risk and poor or unknown (<4 METs) functional capacity	May be reasonable to perform exercise testing with cardiac imaging to assess for myocardial ischemia	IIb	C
Noninvasive pharmacological stress testing	Patients at elevated risk and poor (<4 METs) functional capacity	Reasonable to undergo either DSE or MPI if it will change management	IIa	B
Preoperative coronary angiography		Routine preoperative coronary angiography is not recommended exclusively to reduce perioperative cardiac events	III: No Benefit	B

ACC/AHA the American College of Cardiology/American Heart Association, CCS Canadian Cardiovascular Society, COR class of recommendation, CVD cerebrovascular disease, DSE dobutamine stress echocardiogram, ECG electrocardiogram, HF heart failure, LOE level of evidence, LV left ventricular, MET metabolic equivalent, MI myocardial infarction, MPI myocardial perfusion imaging, NSTE-ACS non-ST-segment elevation acute coronary syndromes, PAD peripheral arterial disease

^aAdapted from Fleisher et al., ACC/AHA practice guidelines [15] and Kristensen et al. ESC/ESA guidelines [32]

Table 10.10

ACC/AHA recommendations for coronary revascularization before endovascular procedure^a

Recommendations	COR	LOE
Revascularization before endovascular procedure is recommended when indicated by existing clinical practice guidelines	I	C
Revascularization is not recommended before endovascular procedure exclusively to reduce perioperative cardiac events	III: no benefit	B

^aAdapted from Fleisher et al., ACC/AHA practice guidelines [15]

Cardiac Risk Models

Standardization of cardiac risk has been used for decades since the pioneer work of Goldman, Eagle, and others. Cardiac risk evaluation is based on clinical characteristics and urgency of procedure, and then extended to laboratory and noninvasive assessments. Among many cardiac risk predicting models, the revised cardiac risk index (RCRI) [33], the American College of Surgeons National Surgical Quality Improvement Program Myocardial Infarction Cardiac Arrest Calculator (ACS NSQIP MICA) [34], ACS NSQIP Surgical Risk Calculator [35], and Vascular Surgery Group Cardiac Risk Index (VSG-CRI) [36] can be applied to predict adverse events in patients undergoing vascular surgery; however, renal risk factor is included in each model. Different from the old models, patients who have been managed with more current standards of care have been included in these models, the ACS NSQIP MICA outperforms the RCRI in some circumstances, and both ACS NSQIP surgical risk calculator and VSG-CRI are procedure specific. ACS NSQIP MICA, ACS NSQIP surgical risk calculator and VSG-CRI are available online for calculation. It should be noted that these models are not exclusively for patients undergoing EVAR with fenestrated, branched or parallel stent grafts, as the original study population for each model included open or endovascular procedures for carotid artery disease, PAD, or aortic aneurysms, mostly infrarenal AAA repairs. In addition, the NSQIP-based calculators have not been validated in an external population outside the NSQIP, and the definition of myocardial infarction (MI) includes only ST-segment MIs or troponin level >3 times normal that occur in symptomatic patients.

Revised Cardiac Risk Index [33]

The RCRI is a six-point index score (Table 10.11) for assessing the risk of major cardiac complications including MI, pulmonary edema, ventricular fibrillation or primary cardiac arrest, and complete heart block following noncardiac surgery. It is simple, has been extensively validated, and provides a good estimate of the preoperative risk. However, the RCRI does not discriminate between low- and high-risk patients undergoing vascular surgery, who generally carry increased perioperative cardiac risk [37].

Table 10.11

Revised cardiac risk index (RCRI) ^a

Risk factor	Points
Ischemic heart disease	1
History of congestive heart failure	1
Creatinine >2 mg/dL (177 μmol/L)	1
Insulin-dependent diabetes	1
History of cerebrovascular disease	1
High-risk surgery (intrathoracic, intra-abdominal, or suprainguinal vascular surgery)	1

Rates of major cardiac complication: Class I (0 point): 0.4 %; Class II (1 point): 1 %; Class III (2 points): 7 %

Class IV (≥3 points): 11 %

^aAdapted from [33]

The ACS NSQIP MICA [34]

Target cardiac complications (Table 10.12) of the ACS NSQIP MICA were defined as cardiac arrest or MI. This model was further tested using 2008 NSQIP data of patients undergoing aortic or other vascular surgery (n = 26,183); the C statistic of the model was 0.746.

Table 10.12

The American College of Surgeons National Surgical Quality Improvement Program Myocardial Infarction Cardiac Arrest Calculator (ACS NSQIP MICA) ^a

Risk factor
●Increasing age
●Creatinine >1.5 mg/dL
●Partially or completely dependent functional status
●ASA physical status class
●Type of surgery
–Anorectal
–Aortic
–Bariatric
–Brain
–Breast
–Cardiac
–Ear, nose, and throat
–Foregut/hepatopancreatobiliary
–Gallbladder/adrenal/appendix/spleen
–Intestinal
–Neck
–Obstetric/gynecological
–Orthopedic
–Other abdomen
–Peripheral vascular
–Skin
–Spine
–Thoracic
–Vein
–Urologic

ASA American Society of Anesthesiologists

^aAdapted from [34]

ACS NSQIP Surgical Risk Calculator [38]

This is a decision-support tool based (Table 10.13) on reliable multi-institutional data, which includes 21 patient-specific variables. The estimated surgery-specific risk of cardiac complications, mortality, and six additional complications can be calculated. However, ACS NSQIP hospitals perform approximately 30 % of all operations in the USA, and only clinical preoperative variables collected by ACS NSQIP could be used in risk models.

Table 10.13

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) variables used in the new universal surgical risk calculators^a

Variable	Categories
Age group, years	●<65
	●65–74
	●75–84
	●≥85
Sex Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Developing Physician-Sponsored Investigational Device Exemption Protocols Comparison of Age (<75 Years Versus ≥75 Years) to Risk of Ventricular Tachyarrhythmias and Implantable Cardioverter Defibrillator Shocks (from the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) EKOS™ ultrasound – accelerated catheter – directed thrombolysis for acutely occluded femoro-popliteal graft Perioperative Care Stay updated, free articles. Join our Telegram channel Tags: Endovascular Aortic Repair Jun 25, 2017 \| Posted by admin in CARDIOLOGY \| Comments Off on Preoperative Evaluation and Clinical Risk Assessment Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access

Thoracic Key

Fastest Thoracic Insight Engine

Preoperative Evaluation and Clinical Risk Assessment

American Society of Anesthesiology (ASA) Physical Status Classification [21]

Society for Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) Comorbidity Score [24]

Cardiac Risk Assessment

Active Cardiac Conditions

Recommendations on Perioperative Cardiovascular Assessment

Cardiac Risk Models

Revised Cardiac Risk Index [33]

The ACS NSQIP MICA [34]

ACS NSQIP Surgical Risk Calculator [38]

Related

Stay updated, free articles. Join our Telegram channel

Full access? Get Clinical Tree

Thoracic Key

Fastest Thoracic Insight Engine

Preoperative Evaluation and Clinical Risk Assessment

American Society of Anesthesiology (ASA) Physical Status Classification [21]

Society for Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) Comorbidity Score [24]

Cardiac Risk Assessment

Active Cardiac Conditions

Recommendations on Perioperative Cardiovascular Assessment

Cardiac Risk Models

Revised Cardiac Risk Index [33]

The ACS NSQIP MICA [34]

ACS NSQIP Surgical Risk Calculator [38]

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