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A program that includes smoking cessation, risk factor reduction, weight loss, and walking will substantially improve exercise tolerance A trial of phosphodiesterase inhibitors, such as cilostazol 100 mg orally twice a day, may be beneficial in approximately two-thirds of patients In the initial stages of a rehabilitation program, substantial benefit may be derived from simply slowing the cadence of walking

Intermittent claudication occurs as a cramping pain brought on by exercise usually located in the calf muscles The pain may extend into the thigh and buttocks with continued exercise It may be unilateral or bilateral Some patients complain only of weakness in the legs when walking, or simply extreme limb fatigue The symptoms are relieved with rest With bilateral symptoms, impotence

Intervention to relieve the obstruction is to be considered if claudication interferes appreciably with the patient s essential activities or employment An aorto-femoral bypass graft that bypasses the occluded segments of the aortoiliac system is a highly effective and durable treatment for this disease This prosthetic graft extends from the infrarenal abdominal aorta to the common femoral arteries High-risk patients may also be treated with a graft from the axillary artery to

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the femoral arteries (axillo-femoral bypass graft) or, in the unusual case of iliac disease limited to one side, a graft from the contralateral femoral artery (fem-fem bypass) The less extensive operations have lower operative risk; however, they are less durable

Sales Documents | Contracts | Contract Data | Define Validity Period Categories As seen in Figure 4-6 the rule is used to simply make a category of date that is used often The category 03 in this example uses the value of 18 and the unit of 3, which represents months, therefore defining the validity period as 18 months

Cramping; pain or tiredness in the calf only with exercise Reduced popliteal or pedal pulses Foot pain at rest, relieved by dependency Foot gangrene or ulceration

Because the flow-limiting stenoses tend to be segmental, occlusive lesions of the aortoiliac segment can be effectively treated with angioplasty and stenting This approach matches the results of surgery for single stenoses but both effectiveness and durability decreases with multiple stenoses

The complications of the aorto-femoral bypass are those of any major abdominal reconstruction in a patient population that has a high penetrance of cardiovascular disease Mortality should be low, in the range of 2 3%, but morbidity is higher with a 5 10% rate of myocardial infarction The total complication rate may be over 10% Complications of endovascular repair include embolization and vessel dissection These are relatively uncommon and the total complication rate should be below 5% with this technique

The finding of a rhythm disturbance on preoperative evaluation should prompt consideration of further cardiac evaluation, particularly when the finding of structural heart disease would alter perioperative management Patients found to have a rhythm disturbance without evidence of underlying heart disease are at low risk for perioperative cardiac complications Management of patients with arrhythmias in the preoperative period should be guided by factors independent of the planned surgery In patients with atrial fibrillation, adequate rate control should be established Symptomatic supraventricular and ventricular tachycardia must be controlled prior to surgery There is no evidence that the use of antiarrhythmic medications to suppress an asymptomatic arrhythmia alters perioperative risk It seems prudent for patients who have indications for a permanent pacemaker to have it placed prior to noncar-

There are few data available regarding the perioperative risks of valvular heart disease independent of associated coronary artery disease or CHF Patients with severe symptomatic aortic stenosis are clearly at increased risk for cardiac complications and should not undergo elective surgery In the most recent series of patients with aortic stenosis who underwent noncardiac surgery, the combined end point of death or nonfatal MI was 31% in patients with

diac surgery When surgery is urgent, these patients may be managed perioperatively with temporary transvenous pacing Patients with bundle branch block who do not meet recognized criteria for a permanent pacemaker do not require pacing during surgery The anesthesiologist must be notified that a patient has an implanted pacemaker or defibrillator so that steps may be taken to minimize the risk of device malfunction caused by electromagnetic interference from the intraoperative use of electrocautery

Pneumonia and respiratory failure requiring prolonged mechanical ventilation are the most important postoperative pulmonary complications and occur in 2 19% of surgical procedures The occurrence of a postoperative pulmonary complication has been associated with a significant increase in hospital length of stay

FIGURE 4-6

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