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Endothelial dysfunction in the perioperative setting
Bernhard Riedel1, Robert Schier
1Division of Cardiac Anesthesiology, Vanderbilt University, Nashville, TN 37232-8274, USA. bernhard.j.riedel@vanderbilt.edu
Abstract:
Although perioperative macrovascular events (eg, myocardial infarction, stroke) are readily evident, their absolute incidence remains relatively low. In contrast, microvascular dysfunction and its role in perioperative morbidity is not easily measured. Microvascular dysfunction is likely to have a greater impact on noncardiovascular complications (eg, wound healing and end-organ failure), through impaired perfusion, than that which is readily appreciated. Inflammation and oxidative stress, such as that induced by surgical trauma, disrupts endothelial homeostasis thereby decreasing the bioavailability of nitric oxide. This predisposes blood vessels to vasoconstriction, inflammation, leukocyte adhesion, thrombosis-factors that contribute to perioperative cardiovascular events at both macrovascular and microvascular level. Current clinical strategies applicable to the perioperative setting that improve microvascular health include preoperative exercise therapy, pharmacologic interventions (eg, statins, newer beta-blockers) and attempts to stimulate mobilization and homing of bone marrow-derived endothelial progenitor cells. Many of these strategies are still in their infancy and large prospective trials that investigate the impact of these therapeutic options on postoperative outcome are eagerly awaited.
Insights
Perioperative microvascular dysfunction, though hard to measure, significantly impacts patient outcomes, potentially causing more complications than macrovascular events. Strategies to improve microvascular health are emerging but require further clinical trials.
Area of Science:
- Cardiovascular Science
- Surgical Complications
- Vascular Biology
Background:
- Perioperative macrovascular events (myocardial infarction, stroke) are evident but infrequent.
- Microvascular dysfunction, though less evident, significantly contributes to perioperative morbidity, impacting noncardiovascular outcomes like wound healing and end-organ failure.
- Surgical trauma induces inflammation and oxidative stress, disrupting endothelial homeostasis and nitric oxide bioavailability, leading to vasoconstriction, thrombosis, and leukocyte adhesion.
Purpose of the Study:
- To highlight the underappreciated role of microvascular dysfunction in perioperative complications.
- To discuss the mechanisms by which inflammation and oxidative stress impair microvascular function.
- To review current and emerging strategies for improving perioperative microvascular health.
Main Methods:
- Literature review of perioperative cardiovascular events and microvascular dysfunction.
- Discussion of the pathophysiological mechanisms linking surgical trauma to endothelial dysfunction.
- Analysis of current clinical strategies for enhancing microvascular health in the perioperative period.
Main Results:
- Microvascular dysfunction is a significant contributor to perioperative morbidity, affecting noncardiovascular outcomes through impaired perfusion.
- Inflammation and oxidative stress post-surgery disrupt endothelial function, promoting vasoconstriction and thrombosis.
- Emerging strategies include preoperative exercise, statins, beta-blockers, and endothelial progenitor cell stimulation.
Conclusions:
- Microvascular dysfunction plays a critical role in perioperative morbidity, often exceeding the impact of macrovascular events.
- Therapeutic strategies targeting microvascular health are promising but require validation through large prospective trials.
- Further research is needed to optimize interventions for improving postoperative outcomes by addressing microvascular impairment.
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