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Practice Clinical Updates

Optimising fitness for major vascular surgery

BMJ 2019; 366 doi: (Published 02 September 2019) Cite this as: BMJ 2019;366:l5002
  1. Ruth Benson, clinical lecturer in vascular surgery1,
  2. Gordon McGregor, clinical exercise physiologist2,
  3. Mishkat Shehata, academic clinical fellow and general practice registrar3,
  4. Christopher Imray, professor of vascular surgery4
  1. 1Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
  2. 2Coventry University NHS Trust, Coventry, UK
  3. 3Unit of Academic Primary Care, University of Warwick, Coventry, UK
  4. 4Warwick Medical School, Coventry University and Exeter University, UK
  1. Correspondence to R A Benson ruth.benson{at}

What you need to know

  • Interventions such as increasing physical activity, optimising management of comorbidities, and smoking cessation can all improve outcomes after surgery

  • There is no guidance on when to introduce exercise interventions before surgery. Earlier is better (eg, at the time of referral)

  • Vascular conditions, including aortic aneurysm, are not a contraindication to low intensity aerobic exercise

Major vascular surgeries, such as aortic aneurysm repair, carotid endarterectomy, and lower limb revascularisation, are increasingly common and carry a high risk. More than 200 million people are affected by peripheral arterial disease worldwide,1 of whom 10-20% require surgery. In the UK, 1.2-1.5% of men over 65 have an abdominal aortic aneurysm, and more than 4000 repairs were performed in 2017.23 Between 7% and 18% of ischaemic strokes are attributed to carotid artery stenosis. About 4000 patients undergo carotid endarterectomy in the UK each year.45

In this article, we review key preoperative interventions that can be started in primary care at the time of referral to a vascular surgeon. The decision whether a patient is fit for surgery will likely be made by the specialist vascular team following evaluation and imaging. However, early interventions initiated in primary care can potentially improve patient outcomes, even when there is uncertainty around a patient’s suitability for surgery.

Search strategy

We searched Medline and the Cochrane database for trials and clinical guidelines relating to abdominal aortic aneurysm surgery, lower limb bypass, and carotid endarterectomy. We considered guidelines from the National Institute for Health and Care Excellence (NICE), the European Society of Vascular Surgery, the European Society of Cardiology, and the Society of Vascular Surgery for key recommendations related to current vascular practice. Where possible, we relied on studies on major vascular surgeries, such as carotid endarterectomy, aneurysm repair, or peripheral limb revascularisation. If evidence was lacking, sources …

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