2014 ESC/ESA Guidelines on non-cardiac surgery
2014; Lippincott Williams & Wilkins; Volume: 31; Issue: 10 Linguagem: Inglês
10.1097/eja.0000000000000150
ISSN1365-2346
AutoresSteen Dalby Kristensen, Juhani Knuuti, Antti Saraste, Stefan D. Anker, Hans Erik Bøtker, Stefan De Hert, Ian Ford, José Ramón González–Juanatey, Bülent Görenek, Guy R. Heyndrickx, Andreas Hoeft, Kurt Huber, Bernard Iung, Keld Per Kjeldsen, Dan Longrois, T F Luescher, Luc Piérard, Stuart J. Pocock, Susanna Price, Marco Roffi, Per Anton Sirnes, Miguel Sousa‐Uva, Vasilis Voudris, Christian Funck‐Brentano,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoThis article is accompanied by the following Invited Commentary: Longrois D, Hoeft A, De Hert S. 2014 European Society of Cardiology/European Society of Anaesthesiology guidelines on non-cardiac surgery: cardiovascular assessment and management. A short explanatory statement from the European Society of Anaesthesiology members who participated in the European Task Force. Eur J Anaesthesiol 2014; 31:513–516. ESC Committee for Practice Guidelines: Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach (Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), Héctor Bueno (Spain), Veronica Dean (France), Christi Deaton (UK), Cetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai (Israel), Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK), Massimo F. Piepoli (Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera (Poland), Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland). ESA Clinical Guidelines Committee: Maurizio Solca (Chairperson) (Italy), Jean-François Brichant (Belgium), Stefan De Herta (Belgium), Edoardo de Robertisb (Italy), Dan Longroisc (France), Sibylle Kozek Langenecker (Austria), Josef Wichelewski (Israel). a Scientific Committee Chairperson & ESA Board Representative, πbNASC Chairperson,cEBA/UEMS representative Document Reviewers: Massimo Piepoli (Review coordinator) (Italy), William Wijns (Review coordinator) (Belgium), Stefan Agewall (Denmark), Claudio Ceconi (Italy), Antonio Coca (Spain), Ugo Corrà (Italy), Raffaele De Caterina (Italy), Carlo Di Mario (UK), Thor Edvardsen (Norway), Robert Fagard (Belgium), Giuseppe Germano (Italy), Fabio Guarracino (Italy), Arno Hoes (Netherlands), Torben Joergensen (Denmark), Peter Jüni (Switzerland), Pedro Marques-Vidal (Switzerland), Christian Mueller (Switzerland), Öztekin Oto (Turkey), Philippe Pibarot (Canada), Piotr Ponikowski (Poland), Olav FM Sellevold (Norway), Filippos Triposkiadis (Greece), Stephan Windecker (Switzerland), Patrick Wouters (Belgium). ESC National Cardiac Societies document reviewers listed in appendix The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines Keywords: Guidelines, Non-cardiac surgery, Preoperative cardiac risk assessment, Preoperative cardiac testing, Preoperative coronary artery revascularization, Perioperative cardiac management, Anti-thrombotic therapy, Beta-blockers, Valvular disease, Arrhythmias, Heart failure, Renal disease, Pulmonary disease, Cerebrovascular disease, Anaesthesiology, Postoperative cardiac surveillance Table of Contents Abbreviations and acronyms 520 Preamble 522 Introduction 523 2.1. Magnitude of the problem 523 2.2. Change in population demographics 524 2.3. Purpose and organization 524 Preoperative evaluation 525 3.1. Surgical risk for cardiac events 525 3.2. Type of surgery 526 3.2.1. Endovascular versus open vascular procedures 526 3.2.2. Open versus laparoscopic or thoracoscopic procedures 526 3.3. Functional capacity 527 3.4. Risk indices 528 3.5. Biomarkers 529 3.6. Non-invasive testing 529 3.6.1. Non-invasive testing of cardiac disease 530 3.6.2. Non-invasive testing of ischaemic heart disease 530 3.7. Invasive coronary angiography 532 Risk-reduction strategies 532 4.1. Pharmacological 532 4.1.1. Beta-blockers 532 4.1.2. Statins 535 4.1.3. Nitrates 536 4.1.4. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers 536 4.1.5. Calcium channel blockers 537 4.1.6. Alpha2 receptor agonists 537 4.1.7. Diuretics 537 4.2. Perioperative management in patients on antiplatelet agents 538 4.2.1. Aspirin 538 4.2.2. Dual antiplatelet therapy 538 4.2.3. Reversal of antiplatelet therapy 539 4.3. Perioperative management in patients on anticoagulants 539 4.3.1. Vitamin K antagonists 539 4.3.2. Non-vitamin K antagonist oral anticoagulants 540 4.3.3. Reversal of anticoagulant therapy 541 4.4. Revascularization 542 4.4.1. Prophylactic revascularization in patients with asymptomatic or stable ischaemic heart disease 543 4.4.2. Type of prophylactic revascularization in patients with stable ischaemic heart disease 544 4.4.3. Revascularization in patients with NSTE-ACS 544 Specific diseases 545 5.1. Chronic heart failure 545 5.2. Arterial hypertension 547 5.3. Valvular heart disease 548 5.3.1. Patient evaluation 548 5.3.2. Aortic stenosis 548 5.3.3. Mitral stenosis 548 5.3.4. Primary aortic regurgitation and mitral regurgitation 548 5.3.5. Secondary mitral regurgitation 549 5.3.6. Patients with prosthetic valve(s) 549 5.3.7. Prophylaxis of infective endocarditis 549 5.4. Arrhythmias 550 5.4.1. New onset ventricular arrhythmias in the preoperative period 550 5.4.2. Management of supraventricular arrhythmias and atrial fibrillation in the preoperative period 550 5.4.3. Perioperative bradyarrhythmias 550 5.4.4. Perioperative management of patients with pacemaker/implantable cardioverter defibrillator 551 5.5. Renal disease 551 5.6. Cerebrovascular disease 553 5.7. Peripheral artery disease 554 5.8. Pulmonary disease 555 5.9. Congenital heart disease 557 Perioperative monitoring 557 6.1. Electrocardiography 557 6.2. Transoesophageal echocardiography 558 6.3. Right heart catheterization 559 6.4. Disturbed glucose metabolism 559 6.5. Anaemia 560 Anaesthesia 560 7.1. Intraoperative anaesthetic management 560 7.2. Neuraxial techniques 561 7.3. Perioperative goal-directed therapy 561 7.4. Risk stratification after surgery 562 7.5. Early diagnosis of postoperative complications 562 7.6. Postoperative pain management 562 Gaps in evidence 563 Summary 563 Appendix 566 References 566 Abbreviations and acronyms AAA abdominal aortic aneurysm ACEI angiotensin converting enzyme inhibitor ACS acute coronary syndromes AF atrial fibrillation AKI acute kidney injury AKIN Acute Kidney Injury Network ARB angiotensin receptor blocker ASA American Society of Anesthesiologists b.i.d. bis in die (twice daily) BBSA beta-blocker in spinal anaesthesia BMS bare-metal stent BNP B-type natriuretic peptide CABG coronary artery bypass graft CAD coronary artery disease CARP Coronary Artery Revascularization Prophylaxis CAS carotid artery stenting CASS Coronary Artery Surgery Study CEA carotid endarterectomy CHA2DS2-VASc cardiac failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65–74 and sex category (female) CI confidence interval CI-AKI contrast-induced acute kidney injury CKD chronic kidney disease CKD-EPI Chronic Kidney Disease Epidemiology Collaboration Cmax maximum concentration CMR cardiovascular magnetic resonance COPD chronic obstructive pulmonary disease CPG Committee for Practice Guidelines CPX/CPET cardiopulmonary exercise test CRP C-reactive protein CRT cardiac resynchronisation therapy CRT-D cardiac resynchronization therapy defibrillator CT computed tomography cTnI cardiac troponin I cTnT cardiac troponin T CVD cardiovascular disease CYP3a4 cytochrome P3a4 enzyme DECREASE Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography DES drug-eluting stent DIPOM Diabetic Postoperative Mortality and Morbidity DSE dobutamine stress echocardiography ECG electrocardiography/electrocardiographically/electrocardiogram eGFR estimated glomerular filtration rate ESA European Society of Anaesthesiology ESC European Society of Cardiology EVAR endovascular abdominal aortic aneurysm repair FEV1 Forced expiratory volume in 1 second HbA1c glycosylated haemoglobin HF-PEF heart failure with preserved left ventricular ejection fraction HF-REF heart failure with reduced left ventricular ejection fraction ICD implantable cardioverter defibrillator IHD ischaemic heart disease INR international normalized ratio IOMC iso-osmolar contrast medium KDIGO Kidney Disease: Improving Global Outcomes LMWH low-molecular weight heparin LOCM low-osmolar contrast medium LV left ventricular LVEF left ventricular ejection fraction MaVS Metoprolol after Vascular Surgery MDRD Modification of Diet in Renal Disease MET metabolic equivalent MRI magnetic resonance imaging NHS National Health Service NOAC non-vitamin K oral anticoagulant NSQIP National Surgical Quality Improvement Program NSTE-ACS non–ST-elevation acute coronary syndromes NT-proBNP N-terminal pro-brain natriuretic peptide O2 oxygen OHS obesity hypoventilation syndrome OR odds ratio P gp platelet glycoprotein PAC pulmonary artery catheter PAD peripheral artery disease PAH pulmonary artery hypertension PCC prothrombin complex concentrate PCI percutaneous coronary intervention POBBLE PeriOperative Beta-BLockadE POISE PeriOperative ISchemic Evaluation POISE-2 Perioperative ischemic evaluation 2 q.d. quaque die (once daily) RIFLE Risk, Injury, Failure, Loss, End-stage renal disease SPECT single photon emission computed tomography SVT supraventricular tachycardia SYNTAX Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery TAVI transcatheter aortic valve implantation TIA transient ischaemic attack TOE transoesophageal echocardiography TTE transthoracic echocardiography UFH unfractionated heparin VATS video-assisted thoracic surgery VHD valvular heart disease VISION Vascular Events In Noncardiac Surgery Patients Cohort Evaluation VKA vitamin K antagonist VPB ventricular premature beat VT ventricular tachycardia 1. PREAMBLE Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk-benefit-ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help the health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate. A great number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA) as well as by other societies and organisations. Because of the impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC/ESA Guidelines can be found on the ESC Web Site (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx). These ESC/ESA Guidelines represent the official position of these two societies on this given topic and are regularly updated. Members of this Task Force were selected by the ESC and ESA to represent professionals involved with the medical care of patients with this pathology. Selected experts in the field undertook a comprehensive review of the published evidence for management (including diagnosis, treatment, prevention and rehabilitation) of a given condition according to the ESC Committee for Practice Guidelines (CPG) and ESA Guidelines Committee policy. A critical evaluation of diagnostic and therapeutic procedures was performed including assessment of the risk-benefit-ratio. Estimates of expected health outcomes for larger populations were included, where data exist. The level of evidence and the strength of recommendation of particular management options were weighed and graded according to predefined scales, as outlined in Tables 1 and 2.Table 1: Classes of recommendationsTable 2: Levels of evidenceThe experts of the writing and reviewing panels filled in declarations of interest forms which might be perceived as real or potential sources of conflicts of interest. These forms were compiled into one file and can be found on the ESC Web Site (http://www.escardio.org/guidelines). Any changes in declarations of interest that arise during the writing period must be notified to the ESC/ESA and updated. The Task Force received its entire financial support from the ESC and ESA without any involvement from the healthcare industry. The ESC CPG supervises and coordinates the preparation of new Guidelines produced by Task Forces, expert groups or consensus panels. The Committee is also responsible for the endorsement process of these Guidelines. The ESC and Joint Guidelines undergo extensive review by the CPG and partner Guidelines Committee and external experts. After appropriate revisions it is approved by all the experts involved in the Task Force. The finalized document is approved by the CPG/ESA for simultaneous publication in the European Heart Journal and joint partner journal, in this instance the European Journal of Anaesthesiology. It was developed after careful consideration of the scientific and medical knowledge and the evidence available at the time of their dating. The task of developing ESC/ESA Guidelines covers not only the integration of the most recent research, but also the creation of educational tools and implementation programmes for the recommendations. To implement the guidelines, condensed pocket guidelines versions, summary slides, booklets with essential messages, summary cards for non-specialists, electronic version for digital applications (smartphones, etc.) are produced. These versions are abridged and, thus, if needed, one should always refer to the full text version which is freely available on the ESC and ESA Websites. The National Societies of the ESC and of the ESA are encouraged to endorse, translate and implement the ESC Guidelines. Implementation programmes are needed because it has been shown that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations. Surveys and registries are needed to verify that real-life daily practice is in keeping with what is recommended in the guidelines, thus completing the loop between clinical research, writing of guidelines, disseminating them and implementing them into clinical practice. Health professionals are encouraged to take the ESC/ESA Guidelines fully into account when exercising their clinical judgment as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies. However, the ESC/ESA Guidelines do not override in any way whatsoever the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient's health condition and in consultation with that patient and the patient's caregiver where appropriate and/or necessary. It is also the health professional's responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription. 2. INTRODUCTION 2.1. Magnitude of the problem The present guidelines focus on the cardiovascular management of patients in whom heart disease is a potential source of complications during non-cardiac surgery. The risk of perioperative complications depends on the condition of the patient before surgery, the prevalence of comorbidities, and the urgency, magnitude, type and duration of the surgical procedure. More specifically, cardiac complications can arise in patients with documented or asymptomatic ischaemic heart disease (IHD), left ventricular (LV) dysfunction, valvular heart disease (VHD), and arrhythmias, who undergo surgical procedures that are associated with prolonged haemodynamic and cardiac stress. In the case of perioperative myocardial ischaemia, two mechanisms are important: (i) a mismatch in the supply–demand ratio of blood flow in response to metabolic demand due to a coronary artery stenosis that may become flow-limiting by perioperative haemodynamic fluctuations; and (ii) acute coronary syndromes (ACS) due to stress-induced rupture of a vulnerable atherosclerotic plaque in combination with vascular inflammation and altered vasomotion as well as haemostasis. LV dysfunction and arrhythmias may occur for various reasons at all ages. Because the prevalence of not only IHD but also VHD and arrhythmias increases with age, perioperative cardiac mortality and morbidity are predominantly an issue in the adult population undergoing major non-cardiac surgery. The magnitude of the problem in Europe can best be understood in terms of: (i) the size of the adult non-cardiac surgical group; and (ii) the average risk of cardiac complications in this cohort. Unfortunately, systematic data on the annual number and type of operations, and on patient outcomes, are only available at a national level in 23 (41%) European countries.1 Moreover, data definitions, as well as data quantity and quality, vary. A recent modelling strategy based on available worldwide data in 2004 estimated the number of major operations to be at an annual rate of 4%.1 When applied to Europe, with an overall population of over 500 million, this figure translates into a crude estimate of 19 million major procedures annually. While the majority of the procedures are performed in patients with minimal cardiovascular risk, 30% of the patients undergo extensive surgical procedures in the presence of cardiovascular comorbidity. Hence, 5.7 million procedures annually are performed in European patients who present with increased risk of cardiovascular complications. Worldwide, non-cardiac surgery is associated with an average overall complication rate of between 7% and 11% and a mortality rate between 0.8% and 1.5% depending on safety precautions.2 Up to 42% of these are caused by cardiac complications.3 When applied to the population in the European Union member states, these figures translate into at least 167 000 cardiac complications, of which 19 000 are life-threatening, due to non-cardiac surgical procedures annually. 2.2. Change in population demographics Within the next 20 years the acceleration in ageing of the population will have a major impact on perioperative patient management. It is estimated that elderly people require surgery four times more often than the rest of the population.4 In Europe, it is estimated that the number of patients undergoing surgery will increase by 25% by 2020. For the same time period, the elderly population will increase by 50%. The total number of surgical procedures may increase even faster because of the rising frequency of interventions with age.5 The results of the United States National Hospital Discharge Survey show that the number of surgical procedures will increase in almost all age groups, and that the largest increase will occur in the middle-aged and elderly. Demographics of patients undergoing surgery show a trend towards an increasing number of elderly patients and comorbidities.6 Although mortality from cardiac disease is decreasing in the general population, the prevalence of IHD, heart failure and cardiovascular risk factors, especially diabetes, is increasing. Among the significant comorbidities in elderly patients presenting for general surgery, cardiovascular disease (CVD) is the most prevalent.7 Age per se, however, seems to be responsible for only a small increase in the risk of complications; greater risks are associated with urgency and significant cardiac, pulmonary and renal disease. Thus, these conditions should have greater impact on the evaluation of patient risk than age alone. 2.3. Purpose and organization These guidelines are intended for physicians and collaborators involved in the preoperative, operative and postoperative care of patients undergoing non-cardiac surgery. The objective is to endorse a standardized and evidence-based approach to perioperative cardiac management. The guidelines recommend a practical, stepwise evaluation of the patient that integrates clinical risk factors and test results with the estimated stress of the planned surgical procedure. This results in an individualized cardiac risk assessment, with the opportunity to initiate medical therapy, coronary interventions, and specific surgical and anaesthetic techniques in order to optimize the patient's perioperative condition. Compared with the non-surgical setting, data from randomized clinical trials, which provide the ideal evidence-base for the guidelines, are sparse. Consequently, when no trials are available on a specific cardiac-management regimen in the surgical setting, data from the non-surgical setting are extrapolated, and similar recommendations made, but with different levels of evidence. Anaesthesiologists, who are experts on the specific demands of the proposed surgical procedure, will usually coordinate the preoperative evaluation. The majority of patients with stable heart disease can undergo low and intermediate risk surgery (Table 3) without additional evaluation. Selected patients require evaluation by a team of integrated multidisciplinary specialists including anaesthesiologists, cardiologists and surgeons, and when appropriate an extended team (e.g. internists, intensivists, pulmonologists or geriatricians).8 Selected patients include those identified by the anaesthesiologist due to suspected or known cardiac disease with sufficient complexity to carry a potential perioperative risk (e.g. congenital heart disease, unstable symptoms or low functional capacity), patients in whom preoperative medical optimization is expected to reduce perioperative risk before low- and intermediate-risk surgery, and patients with known or high risk of cardiac disease undergoing high-risk surgery. Guidelines have the potential to improve postoperative outcomes and highlight the existence of a clear opportunity for improving the quality of care in this high-risk group of patients. In addition to promoting an improvement in immediate perioperative care, guidelines should provide long-term advice.Table 3: Surgical risk estimate according to type of surgery or interventiona,bBecause of the availability of new evidence and the international impact of the controversy regarding the DECREASE trials, the ESC/ESA and American College of Cardiology/American Heart Association both began the process of revising their respective guidelines concurrently. The respective writing committees independently performed their literature review and analysis, and then developed their recommendations. Once peer review of both guidelines was completed, the writing committees chose to discuss their respective recommendations regarding beta-blocker therapy and other relevant issues. Any differences in recommendations were discussed and clearly articulated in the text. However, the writing committees aligned a few recommendations to avoid confusion within the clinical community except where international practice variation was prevalent. Following the development and introduction of perioperative cardiac guidelines, their effect on outcome should be monitored. The objective evaluation of changes in outcome will form an essential part of future perioperative guideline development.Table: No title available.3. PREOPERATIVE EVALUATION 3.1. Surgical risk for cardiac events Cardiac complications after non-cardiac surgery depend on patient-related risk factors, on the type of surgery and on the circumstances under which it takes place.9 Surgical factors that influence cardiac risk are related to the urgency, invasiveness, type and duration of the procedure, as well as the change in body core temperature, blood loss, and fluid shifts.5 Every operation elicits a stress response. This response is initiated by tissue injury and mediated by neuroendocrine factors, and may induce sympatho-vagal imbalance. Fluid shifts in the perioperative period add to the surgical stress. This stress increases myocardial oxygen demand. Surgery also causes alterations in the balance between prothrombotic and fibrinolytic factors, potentially resulting in increased coronary thrombogenicity. The extent of such changes is proportionate to the extent and duration of the intervention. These factors, together with patient position, temperature management, bleeding, and type of anaesthesia may contribute to haemodynamic derangements leading to myocardial ischaemia and heart failure. General, locoregional and neuraxial anaesthesia differ regarding the stress response evoked by surgery. Less invasive anaesthetic techniques may reduce early mortality in patients at intermediate- to high-cardiac risk and limit postoperative complications.10 Although patient-specific factors are more important than surgery-specific factors in predicting the cardiac risk for non-cardiac surgical procedures, the type of surgery cannot be ignored.9 With regard to cardiac risk, surgical interventions, which include open or endovascular procedures, can be broadly divided into low-risk, intermediate-risk and high-risk groups, with estimated 30-day cardiac event rates (cardiac death and myocardial infarction) of 5%, respectively (Table 3). The need for, and value of, preoperative cardiac evaluation will also depend on the urgency of surgery. In the case of emergency surgical procedures, such as those for ruptured abdominal aortic aneurysm (AAA), major trauma, or for a perforated viscus, cardiac evaluation will not change the course and result of the intervention but may influence the management in the immediate perioperative period. In non-emergency but urgent surgical conditions such as bypass for acute limb ischaemia or treatment of bowel obstruction, the morbidity and mortality of the untreated underlying condition may outweigh the potential cardiac risk related to the intervention. In these cases, cardiological evaluation may influence the perioperative measures taken to reduce the cardiac risk but will not influence the decision to perform the intervention. In some cases, the cardiac risk can also influence the type of operation and guide the choice to less-invasive interventions, such as peripheral arterial angioplasty instead of infrainguinal bypass, or extra-anatomical reconstruction instead of an aortic procedure, even when these may yield less favourable results in the long term. Finally, in some situations, the cardiac evaluation (in as far as it can reliably predict perioperative cardiac complications and late survival) should be taken into consideration when deciding whether to perform an intervention or manage conservatively. This is the case in certain prophylactic interventions such as the treatment of small AAAs or asymptomatic carotid stenosis where the life expectancy of the patient and the risk of the operation are important factors in evaluating the potential benefit of the surgical intervention. 3.2. Type of surgery In general, endoscopic and endovascular techniques speed recovery, decrease hospital stay, and reduce the rate of complications.12 However, randomized clinical trials comparing laparoscopic with open techniques exclude older, sicker and urgent patients, and results from an expert-based randomized trial (laparoscopic versus open cholecystectomy) have shown no significant differences in conversion rate, pain, complications, length of hospital stay or readmissions.13 The wide variety of surgical procedures in a myriad of different contexts makes assigning a specific risk of a major adverse cardiac event to each procedure difficult. When alternative methods to the classical open surgery are considered, either through endovascular or less-invasive endoscopic procedures, the potential trade-offs between early benefits due to reduced morbidity and mid- to long-term efficacy need to be taken into account. 3.2.1. Endovascular versus open vascular procedures Vascular interventions are of specific interest, not only because they carry the highest risk of cardiac complications, but also because of the many studies that have shown that this risk can be influenced by adequate perioperative measures in these patients.14 Open aortic and infrainguinal procedures have both to be considered as high-risk procedures. Although it is a less-extensive intervention, infrainguinal revascularization entails a cardiac risk similar to or even higher than that of aortic procedures. This can be explained by the higher incidence of diabetes, renal dysfunction, IHD and advanced age in this patient group. This also explains why the risk related to peripheral artery angioplasties, which are minimally invasive procedures, is not negligible. Endovascular AAA repair (EV
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