Review Prehabilitation for Vascular Surgery Patients: Challenges and Opportunities

Article:
Shovel L and Morkane C. Review Prehabilitation for Vascular Surgery Patients: Challenges and Opportunities. Canadian Journal of Cardiology 38 (2022) 645e653

What is already known:
In ERAS, prehabilitation is a common practice to improve the patient’s functional capacity before major surgery, especially in frailty and physical inactivity people. Prehabilitation is important in case of significant physiologic stressors in terms of dietetic and psychologic support to improve the patient’s outcome. This approach allows the patient to have a quicker recovery and a reduced length of hospital stay and reduced postoperative morbidity. During the pandemic, the patient performed prehabilitation with home-based exercise; meanwhile, usually an expert paramedic would monitor the patient evaluating for the best exercise. In vascular surgery, a patient’s preoperative functional status plays a crucial role in their ability to withstand the surgical stress response associated with peripheral arterial disease (PAD) or abdominal aortic aneurysm (AAA) repair, even though the exercise should not be too heavy because the PAD could affect the reduction in the activity and the aneurysmatic pathology could be negatively affected by the intensive exercise. So management of risk factors and exercise before the intervention are the prehabilitation conditions to improve the outcome.

What this paper adds:
Since prehabilitation models remain heterogeneous, with little consistency or best practice agreed on in the literature, this review can explore what could be a good approach and protocol for it. While in vascular surgery there is an apparent lack of good-quality evidence of benefit, in oncologic one, there are strong indications that prehabilitation is working but face-to-face group classes are still standard of care because, otherwise, exercise programs are likely to fail or be significantly less successful.
Regarding prehabilitation, before abdominal aortic aneurysm treatment, different papers reported implementation of the exercise regimens with training intensity and frequency varying wildly between studies: inspiratory muscle training for a minimum of 2 weeks before surgery, others assessing the impact of 6 weeks of preoperative supervised exercise, the feasibility of high-intensity training (HIT) 3 times per week for 4 weeks, and investigation of preoperative physical activity through 6-minute walking distance.
Literature disagrees about the preoperative exercise. Some authors suggest a benefit in the length of stay and quicker recovery; others reported utterly different data. These topics make it difficult to recommend prehabilitation and exercise as a standard of care in vascular surgery, and it is considered a future research target.
In fact, large AAA (more than 7 cm) has a significant risk of rupture due to potential exercise-induced blood pressure surges; training in patients with early (< 5.5 cm) AAA disease has been well established as a safe activity. Exercise may help in AAA suppression having a protective role against its increasing and expansion. For this reason, prehabilitation programs offer an opportunity to begin exercise training and modify lifestyle behavior when aneurysms are small and not considered for treatment yet: patients may be psychologically more receptive to risk factors and incorrect behavior changes during this time. In this program costs should be a problem to address because the vascular perioperative pathways (also prehabilitation) involve different healthcare figures such as vascular surgeons, vascular nurse specialists, physiotherapists and exercise therapists, dieticians, occupational therapists, and anesthesiologists. In PAD, claudicants and amputees may find the generic or group exercises used in prehabilitation unfeasible because of either pain or inability to stand or balance. These patients may require sitting or upper limb exercises delivered at home or in person. Physical fitness benefits almost every context of health and disease, and mounting evidence confirms the relationship between physical fitness and improved perioperative outcomes.