Authors:

• Dr Michele Homsy, Consultant Anaesthetist, University Hospitals Sussex (East)
• Dr Vanessa Fludder, Consultant in Anaesthetics and Perioperative Medicine, University Hospitals Sussex (East); Honorary Clinical Senior Lecturer, Brighton and Sussex Medical School (BSMS)

Vascular services in the NHS are delivered within hub-and-spoke networks, concentrating complex arterial surgery in specialist centres while maintaining local access to diagnostics and outpatient care.

Most patients undergoing vascular surgery are either current or ex-smokers or have diabetes. They usually have co-morbidities including hypertension, coronary or cerebrovascular disease, COPD, or renal dysfunction. The role of the Vascular Anaesthesia Society of Great Britain and Ireland (VASGBI) is to promote excellence in the perioperative care of patients with vascular disease through education, networking, supporting research, and quality improvement. Increasing procedural complexity, national audit data, and recent guideline publications provide context for understanding current challenges and future priorities.

Recently published guidance

The NCEPOD report Risking Life and Limb (November 2025) identified significant delays in recognition, referral, and inter-hospital transfer of patients presenting with acute limb ischaemia. The report emphasised the need for clear and accessible guidance to facilitate timely referral and provision of limb-saving procedures. Here, anaesthetists have a key role in resuscitation and stabilisation as well as in advocating timely intervention.

Enhanced perioperative care is now central to vascular anaesthesia. International Enhanced Recovery after Surgery (ERAS) guidelines for the perioperative care of patients undergoing both open aortic and peripheral arterial bypass surgery have been published recently. These guidelines emphasise structured perioperative pathways, including optimisation of anaemia, frailty, and cardiorespiratory disease. Recommended practice has resulted in many vascular anaesthetists having preoperative clinics in their job plans.

A 2023 Delphi consensus statement highlighted wide variation in practice across the UK for suspected acute aortic syndrome (mostly aortic dissection) and made recommendations to standardise referral and transfer pathways to regional specialist aortic centres. Following this, guidance on diagnosis, imaging, haemodynamic stabilisation, and adult critical-care transfer has been developed. For anaesthetists working in vascular hubs, this entails increased exposure to emergency thoracic endovascular repair and measures to reduce spinal cord ischaemia. In the spokes, anaesthetists may be required to assist with safe and timely transfer.

Current trends

Regional anaesthesia is increasingly used, both for theatre-based procedures and for analgesia in patients with chronic limb-threatening ischaemia (CLTI). Although national audit datasets don’t yet reliably capture details of specific anaesthetic techniques, observational studies suggest that regional or local may be associated with lower rates of perioperative cardiopulmonary complications. In striving to provide optimal pain relief for patients admitted with CLTI (while reducing traditional reliance on opioid analgesics) it is now common for vascular hubs to have a peripheral nerve catheter service. This approach has been shown to be effective in controlling pain, reducing side effects, increasing emotional wellbeing and enabling elevation, facilitating reduced leg swelling and even the need for amputation.

Complex endovascular procedures, fenestrated and branched endovascular aneurism repair (EVAR), and combined open-endovascular interventions have led to increased use of hybrid theatres, enabling immediate conversion to open surgery and reduced requirement for staged procedures, improving procedural efficiency. Hybrid operating environments can be challenging for anaesthetists, in part due to constraints imposed by imaging equipment. Management of major haemorrhage in isolated hybrid theatres demands flexibility, adaptability, and heightened situational awareness. Current trends highlight the need for continual development of up-to-date guidance to facilitate complex multidisciplinary teamwork; many examples can be found on the VASGBI website.

The future

Management of carotid disease continues to evolve. National Vascular Registry (NVR) data demonstrate a 33% reduction in carotid endarterectomy volumes from 2014 to 2024, while carotid artery stenting (CAS) remains uncommon. The expansion of stroke thrombectomy services in the UK has increased the possibility of synchronous carotid stenting. The 2023 European Society of Vascular Surgery carotid guidance endorses this option in selected patients. These developments suggest that stroke thrombectomy pathways may increase treatment of carotid stenosis by CAS. This, and the improvement in best medical therapy (statins and antiplatelets) is likely to result in a continued reduction in carotid endarterectomy procedures in the coming years.

Education and workforce development remain key priorities. Exposure to vascular anaesthesia during training can be variable, as not all anaesthetists in training rotate through a vascular hub. The VASGBI provide a biennial one-day symposium aimed at anaesthetists in training, covering core knowledge essential to the safe care of patients undergoing vascular surgery. We hope that the new vascular chapter of the RCoA Audit and QI compendium will provide inspiration for service development work across the country.

According to the Office for National Statistics, the prevalence of smoking continues to fall annually and is at the lowest level since records began in 2011. Will this mean a reduction in the prevalence of smoking-related vascular disease, and thus vascular surgical procedures in future years? Time will tell.

As vascular services continue to adapt, anaesthetists will remain central to delivering safe, responsive and individualised care.