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British Journal of Anaesthesia
BJA

Hypertension and cataract surgery under loco-regional anaesthesia: not to be ignored?

      The presence of sight-impairing opacification, cataract, is an age-related condition. Modern phacoemulsification procedures allow cataract removal safely and efficiently under loco-regional anaesthesia.
      • Kumar CM
      • Eke T
      • Dodds C
      • et al.
      Local anaesthesia for ophthalmic surgery–new guidelines from the Royal College of Anaesthetists and the Royal College of Ophthalmologists.
      Increasing numbers of patients with comorbid conditions, including dementia, diabetes mellitus, cardiovascular disease on concurrent antithrombotics and hypertension, present for cataract surgery. The British Journal of Anaesthesia has recently addressed anaesthesia-related issues for ophthalmic surgery in patients with dementia,
      • Kumar CM
      • Seet E
      Cataract surgery in dementia patients-time to reconsider anaesthetic options.
      diabetes mellitus
      • Kumar CM
      • Seet E
      • Eke T
      • Dhatariya K
      • Joshi GP
      Glycaemic control during cataract surgery under loco-regional anaesthesia: a growing problem and we are none the wiser.
      and anticoagulation.
      • Kumar CM
      • Seet E
      Stopping antithrombotics during regional anaesthesia and eye surgery: crying wolf?.
      This editorial addresses issues related specifically to hypertension. Hypertension impacts 1 billion adults across the globe affecting up to 80% of patients in the general population aged 60 yr and older.
      • Kearney PM
      • Whelton M
      • Reynolds K
      • Muntner P
      • Whelton PK
      • He J
      Global burden of hypertension: analysis of worldwide data.
      Like the sensation of a fishbone stuck in the throat, the impact of hypertension on perioperative outcome after cataract surgery should not be ignored without meticulous interrogation.

      Definition of hypertension

      Published guidelines and reports from various professional bodies reflect different thresholds for hypertension classifications and management,
      • Chobanian AV
      • Bakris GL
      • Black HR
      • et al.
      The Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report.
      • Hartle A
      • McCormack T
      • Carlisle J
      • et al.
      The measurement of adult blood pressure and management of hypertension before elective surgery: joint guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society.
      Hypertension in adults: diagnosis and management | Guidance and guidelines | NICE [Internet].
      indicating ambiguity and a need for worldwide harmonization.
      • Rehan HS
      • Grover A
      • Hungin AP
      Ambiguities in the guidelines for the management of arterial hypertension: Indian perspective with a call for global harmonization.
      The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) in 2003 defined hypertension as systolic blood pressure (SBP) greater than 140 mm Hg and/or diastolic blood pressure (DBP) greater than 90 mm Hg.
      • Chobanian AV
      • Bakris GL
      • Black HR
      • et al.
      The Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report.
      The 2014 JNC8 Report focused on hypertension treatment targets with dichotomized recommendation to initiate pharmacological treatment depending on a cut-off age of ≥60 yr to lower blood pressure to <150/90 mm Hg.
      • James PA
      • Oparil S
      • Carter BL
      • et al.
      2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
      The updated 2016 National Institute for Health and Care Excellence (NICE) Guidelines characterized Stage 1, Stage 2 and severe hypertension (≥180/110 mm Hg).
      Hypertension in adults: diagnosis and management | Guidance and guidelines | NICE [Internet].
      Recently, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and British Hypertension Society (BHS) produced joint guidelines
      • Hartle A
      • McCormack T
      • Carlisle J
      • et al.
      The measurement of adult blood pressure and management of hypertension before elective surgery: joint guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society.
      for simplified anaesthesia management and categorized hypertension into 4 grades: Grade 1 (SBP 140–159 mm Hg and/or DBP 90–99 mm Hg); Grade 2 (SBP 160–179 mm Hg and/or DBP 100–109 mm Hg); Grade 3 (SBP 180–209 mm Hg and/or DBP 110–119 mm Hg); and Grade 4 (SBP ≥210 mm Hg and/or DBP ≥120 mm Hg).
      Recent NICE guidelines
      Hypertension in adults: diagnosis and management | Guidance and guidelines | NICE [Internet].
      iterates the important role of hypertension as a preventable cause of premature morbidity and mortality. A blood pressure threshold of systolic 180 mm Hg and diastolic 110 mm Hg is considered harmful and heralds an association with target organ damage. It is argued that the grades of hypertension might not be applicable to the perioperative setting. Perioperative hypertension can differ in mechanism, treatment responsiveness, as well as consequences depending on patient characteristics and invasiveness of surgical procedure. This leads to controversies with regards to perioperative targets for blood pressure.
      • Hartle A
      • McCormack T
      • Carlisle J
      • et al.
      The measurement of adult blood pressure and management of hypertension before elective surgery: joint guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society.

      Perioperative hypertension—why worry?

      The silver tsunami (population ageing) has arrived on the shores of many countries, carrying with it a tide of patients with cataracts and concomitant hypertension. Pre-existing hypertension is well recognized to be the most common chronic condition in approximately half of patients presenting for cataract surgery. This can be further exacerbated perioperatively by inadvertent omission and/or withdrawal of antihypertensive drugs, anxiety, phenylephrine eye drops administration, hypothermia and pain during surgery. Anaesthetists and ophthalmologists worry that perioperative hypertension might increase the risk of adverse medical events (e.g. cardiovascular and neurological) and the surgical risk of sight-threatening bleeding occurring before, during or after cataract surgery. Bleeding into or around the eye has the potential to cause blindness, particularly in large incision cataract surgery.

      Quantifying the medical risk

      There is little good evidence to quantify the association between the level of blood pressure and systemic risk during cataract surgery. This is in part because adverse cardiovascular events (e.g. hypertensive heart failure, cardiac death, non-fatal myocardial infarction or non-fatal cardiac arrest) and neurological events (e.g. strokes) are rare and most studies are too small to draw conclusions. In addition, most of the relevant publications involve a degree of intervention for patients who have higher blood pressure, with intervention rates varying significantly between studies.
      One of the largest cohort studies two decades ago looked at almost 20 000 elective cataract operations in North America. The baseline incidence of pre-existing hypertension was 47%.
      • Schein OD
      • Katz J
      • Bass EB
      • et al.
      The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery.
      The intraoperative adverse hypertensive event (defined as arterial blood pressure ≥140/90 mm Hg requiring antihypertensive treatment) was 1.1% (215 patients). There were no cerebrovascular adverse events or intraoperative deaths,
      • Schein OD
      • Katz J
      • Bass EB
      • et al.
      The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery.
      albeit ophthalmic surgery and anaesthesia in the mid-1990s might not reflect current practice.
      A retrospective cohort study
      • Alboim C
      • Kliemann RB
      • Soares LE
      • Ferreira MM
      • Polanczyk CA
      • Biolo A
      The impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery: a cohort study.
      of about 1000 consecutive patients (50 yr of age or older) undergoing elective cataract surgery in Brazil found that hypertension occurred in 319 (33%) patients. Eighty-nine patients (9.3%) had an initial SBP ≥180 mm Hg, which was not associated with higher risk of posterior capsule rupture or postoperative adverse events. There were no major cardiovascular events during surgery or in the first week, and logistic regression analysis showed no association between initial SBP ≥180 mm Hg and emergency visits/hospitalization within 7 days.
      A study from the UK looked at 734 hypertensive patients who were previously well controlled. The blood pressure in most patients immediately before surgery was mean 171/73 mm Hg. Eighty-seven patients (12%) had SBP ≥180 mm Hg or DBP ≥110 mm Hg and surgery went ahead. There were no systemic complications, such as cardiac arrest, myocardial infarction or stroke.
      • Agarwal PK
      • Mathew M
      • Virdi M
      Is there an effect of perioperative blood pressure on intraoperative complications during phacoemulsification surgery under local anaesthesia?.
      These findings were affirmed by a recent study concluding that preoperative evaluation had no role in reducing adverse events in patients undergoing cataract surgery, and hypertensive episodes observed in this patient population were not associated with any adverse medical or surgical outcomes.
      • Guerrier G
      • Rondet S
      • Hallal D
      • et al.
      Risk factors for intraoperative hypertension in patients undergoing cataract surgery under topical anaesthesia.
      Guerrier and colleagues
      • Guerrier G
      • Rondet S
      • Hallal D
      • et al.
      Risk factors for intraoperative hypertension in patients undergoing cataract surgery under topical anaesthesia.
      studied 514 cataract surgery patients under topical anaesthesia. The incidence of hypertension was 10.4%, which was not significantly reduced by premedication. There was no significant difference between patients with or without hypertension in the rate of hypertensive events.
      A large case series from Holland looked at 6961 cataract cases (4347 patients) undergoing phacoemulsification under topical/intracameral anaesthesia without sedation and without the presence of an anaesthesiologist.
      • Koolwijk J
      • Fick M
      • Selles C
      • et al.
      Outpatient cataract surgery: incident and procedural risk analysis do not support current clinical ophthalmology guidelines.
      Blood pressure was measured preoperatively, but patients were only monitored during surgery with pulse oximetry in accordance with the 2012 UK guideline.
      • Kumar CM
      • Eke T
      • Dodds C
      • et al.
      Local anaesthesia for ophthalmic surgery–new guidelines from the Royal College of Anaesthetists and the Royal College of Ophthalmologists.
      In this series, nearly 2500 patients (57%) had diagnosed hypertension (measured SBP ≥160 mm Hg and/or DBP ≥90 mm Hg, or both). However, only one case was cancelled on the day, and this was because of tachycardia. There were no calls to the emergency team during or after surgery, no intraocular haemorrhage, no unplanned hospital admission and no morbidity or mortality attributed to this study.
      Fear remains among clinicians that untreated or poorly controlled hypertensive patients can have significant blood pressure fluctuations including hypertensive crisis (SBP ≥180 mm Hg and/or DBP ≥110 mm Hg) that might increase the risks of adverse perioperative cardiovascular and neurological events.
      • Hanada S
      • Kawakami H
      • Goto T
      • Morita S
      Hypertension and anesthesia.
      • Howell SJ
      • Sear JW
      • Foëx P
      Hypertension, hypertensive heart disease and perioperative cardiac risk.
      It is generally accepted that Stage 1–2 preoperative hypertension does not influence perioperative outcome, while evidence regarding severe hypertension is lacking.
      • Hanada S
      • Kawakami H
      • Goto T
      • Morita S
      Hypertension and anesthesia.
      • Howell SJ
      • Sear JW
      • Foëx P
      Hypertension, hypertensive heart disease and perioperative cardiac risk.
      In fact, the American College of Cardiology/American Heart Association guidelines do not even mention hypertension, probably because of lack of evidence of its influence on perioperative outcome.
      • Fleisher LA
      • Fleischmann KE
      • Auerbach AD
      • et al.
      2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
      Nevertheless, it is clear that hypertension should not be considered in isolation as other factors might influence perioperative outcome in patients with raised blood pressure, such as the presence of other comorbid conditions, the patient's functional capacity, and surgical urgency and invasiveness. Unfortunately, identifying hypertensive patients undergoing cataract surgery under loco-regional anaesthesia who are most vulnerable to perioperative complications will be difficult because of their extremely low complication rate.

      Quantifying the surgical risk

      Does uncontrolled hypertension make cataract surgery more risky under loco-regional anaesthesia? Loco-regional anaesthesia is known to reduce hormonal and metabolic response to cataract surgery and offers metabolic stability in patients who often have severe endocrine and metabolic diseases.
      • Barker JP
      • Robinson PN
      • Vafidis GC
      • Burrin JM
      • Sapsed-Byrne S
      • Hall GM
      Metabolic control of non-insulin-dependent diabetic patients undergoing cataract surgery: comparison of local and general anaesthesia.
      There is little hard evidence regarding any association between hypertension, surgical difficulties or haemorrhagic complications. Significant bleeding is extremely rare during phacoemulsification cataract surgery and even large incision extracapsular or intracapsular cataract surgery.
      The aforementioned study of 734 hypertensive patients, who had no perioperative intervention for elevated blood pressure, had no significant difference in surgical complications compared with normotensives.
      • Agarwal PK
      • Mathew M
      • Virdi M
      Is there an effect of perioperative blood pressure on intraoperative complications during phacoemulsification surgery under local anaesthesia?.
      In a prospective study of 108 cases of suprachoroidal haemorrhage complicating cataract surgery from 13 centres participating in the United Kingdom British Ophthalmological Surveillance Unit,
      • Ling R
      • Kamalarajah S
      • Cole M
      • James C
      • Shaw S
      Suprachoroidal haemorrhage complicating cataract surgery in the UK: a case control study of risk factors.
      univariate analysis of potential risk factors found no significant effect of hypertension. Often, cataract and glaucoma procedures are combined. Delayed suprachoroidal haemorrhage (DSCH) is mainly a concern in glaucoma surgery when intraocular pressureis low. Of 2752 glaucoma surgeries performed, 29 cases of DSCH (1%) were observed and hypertension was identified as a risk factor.
      • Jeganathan VSE
      • Ghosh S
      • Ruddle JB
      • Gupta V
      • Coote MA
      • Crowston JG
      Risk factors for delayed suprachoroidal haemorrhage following glaucoma surgery.
      Longstanding hypertension, however, is known to increase the fragility of ocular blood vessels, hence might have caused bleeding.
      • Fraser-Bell S
      • Symes R
      • Vaze A
      Hypertensive eye disease: a review.
      Some antihypertensive medications (particularly alpha-blockers) can cause surgical difficulties because of intraoperative floppy iris syndrome and there is limited evidence that hypertension might be a risk factor.
      • Chatziralli IP
      • Peponis V
      • Parikakis E
      • Maniatea A
      • Patsea E
      • Mitropoulos P
      Risk factors for intraoperative floppy iris syndrome: a prospective study.
      • Enright JM
      • Karacal H
      • Tsai LM
      Floppy iris syndrome and cataract surgery.

      Should elective cataract surgery be postponed in patients with uncontrolled hypertension?

      Hypertension is a common reason to cancel or postpone elective surgery—this can have significant psychological, social and financial implications for patients and their families. A Brazilian study found that (22%) of cataract operations were postponed because of uncontrolled hypertension.
      • Magri MP
      • Espindola RF
      • Santhiago MR
      • Mercadante EF
      • Kara Junior, N
      Cancellation of cataract surgery in a public hospital.
      A sprint audit of elective surgical patients from the UK found that 1–3% of the cohort had further investigations arising from blood pressure measurement, and half of these had their elective surgery postponed.
      • Hartle A
      • McCormack T
      • Carlisle J
      • et al.
      The measurement of adult blood pressure and management of hypertension before elective surgery: joint guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society.
      This was a key impetus that prompted joint guidelines by the AAGBI and BHS for hypertension management before elective surgery.
      • Hartle A
      • McCormack T
      • Carlisle J
      • et al.
      The measurement of adult blood pressure and management of hypertension before elective surgery: joint guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society.
      Overall, hypertension is the reason for about 10% of surgical cancellations and in excess of 10% of intraoperative interventions.
      A fundamental question relates to the consequences of uncontrolled hypertension in cataract surgery patients. For this we must look at evidence from centres that do not have a culture of intervention for high blood pressure. The Dutch case series described above had no systemic adverse events among nearly 4000 patients with raised blood pressure undergoing cataract surgery,
      • Koolwijk J
      • Fick M
      • Selles C
      • et al.
      Outpatient cataract surgery: incident and procedural risk analysis do not support current clinical ophthalmology guidelines.
      despite the fact that none of the cases was cancelled because of hypertension on the day. There were no calls to the emergency team during or after surgery, intraocular haemorrhage, unplanned hospital admission, morbidity or mortality attributed to this process during the whole of the study period. The aforementioned UK series
      • Agarwal PK
      • Mathew M
      • Virdi M
      Is there an effect of perioperative blood pressure on intraoperative complications during phacoemulsification surgery under local anaesthesia?.
      of 734 hypertensive cataract patients, including 87 patients (12%) with SBP ≥180 mm Hg or DBP ≥110 mm Hg and no systemic adverse events, concluded that patients undergoing cataract surgery under local anaesthesia should not be cancelled because of raised blood pressure in the immediate preoperative period.
      Recently, the AAGBI and BHS promulgated guidelines for the management of hypertension before surgery.
      • Hartle A
      • McCormack T
      • Carlisle J
      • et al.
      The measurement of adult blood pressure and management of hypertension before elective surgery: joint guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society.
      Recommendations include that preoperative assessment clinics need not measure the blood pressure of patients being prepared for elective surgery whose systolic and diastolic blood pressures are below 160/100 mm Hg in the referral letter from primary care. This recommendation is based upon the concept that the baseline blood pressure should be the patient's long-term blood pressure and not that obtained on the day of surgery. White coat hypertension is an ever-present problem, and blood pressure recording at the time of admission or in the holding area does not reflect the true hypertensive status.
      The evidence for postponing elective cataract surgery in patients with raised blood pressure is sparse and of limited quality. It is difficult to agree on an absolute value of elevated blood pressure above which elective cataract surgery should be deferred for hypertension treatment.
      • Hanada S
      • Kawakami H
      • Goto T
      • Morita S
      Hypertension and anesthesia.
      • Howell SJ
      • Sear JW
      • Foëx P
      Hypertension, hypertensive heart disease and perioperative cardiac risk.
      Nevertheless, it is increasingly clear that uncontrolled hypertension should not be the sole reason for cancellation of cataract surgery.
      • Guerrier G
      • Rondet S
      • Hallal D
      • et al.
      Risk factors for intraoperative hypertension in patients undergoing cataract surgery under topical anaesthesia.
      • Koolwijk J
      • Fick M
      • Selles C
      • et al.
      Outpatient cataract surgery: incident and procedural risk analysis do not support current clinical ophthalmology guidelines.
      The decision to postpone elective cataract surgery in a patient with raised blood pressure depends upon several factors, including comorbidities, surgical procedure and anaesthetic technique.
      Patients with SBP <180 mm Hg and/or DBP <110 mm Hg can proceed to elective cataract surgery even if they do not have a documented long-term blood pressure measurement from the primary care physician. Patients with SBP ≥180 mm Hg and/or DBP ≥110 mm Hg, who are more likely to have target organ damage, may be at a small increased incidence of perioperative major adverse cardiovascular and neurological events. However, this group of patients has not been subjected to rigorous trials of perioperative interventions. Most of the evidence is for patients undergoing major cardiac or vascular surgery.

      Treatment of patients with high blood pressure before cataract surgery

      In the event that a patient is deferred for hypertension treatment, effective risk reduction may require 6–8 weeks of treatment to allow regression of vascular and endothelial changes.
      • Prys-Roberts C
      Isolated systolic hypertension: pressure on the anaesthetist?.
      Rapid or extreme blood pressure lowering may increase the risk of cerebral and coronary ischaemia. Inconvenience, anxiety, continuing risk of falls and accidents from delaying cataract surgery must therefore be weighed against the benefits of hypertension treatment. It has been suggested that anaesthetists should gauge their concern for a patient diagnosed with hypertension by the calculated 5 yr rate of cardiovascular events, not by blood pressure measurement per se.
      • Hartle A
      • McCormack T
      • Carlisle J
      • et al.
      The measurement of adult blood pressure and management of hypertension before elective surgery: joint guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society.
      Blood pressure control should be optimized prior to surgery in patients in whom hypertension is associated with accompanying significant risk factors, such as diabetes mellitus, coronary artery disease, peripheral vascular disease, impaired renal function, smoking or hypercholesterolaemia.
      • Hartle A
      • McCormack T
      • Carlisle J
      • et al.
      The measurement of adult blood pressure and management of hypertension before elective surgery: joint guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society.

      Is there evidence for treatment of hypertension during cataract surgery?

      While we wait for higher level and consistent evidence in the perioperative domain, it would be prudent to adopt the clinical practice followed in patients arriving in emergency departments with hypertensive crisis (SBP ≥180 mm Hg or DBP ≥110 mm Hg). Patients with a hypertensive emergency (those with presence of acute end-organ damage) usually require immediate reduction of blood pressure, and by extrapolation should have elective surgery postponed. On the other hand, patients with hypertensive urgency (those without acute target-organ involvement) usually have their blood pressure reduced over a 24–48 h period. It is unclear if elective cataract surgery can prudently proceed in the latter scenario.
      The complex interplay between the factors that influence perioperative arterial blood pressure makes it difficult to determine the optimal approach to management. Anxiety is an important factor associated with some degree of elevated preoperative and intraoperative blood pressure in day surgery patients undergoing cataract surgery.
      • Guerrier G
      • Rondet S
      • Hallal D
      • et al.
      Risk factors for intraoperative hypertension in patients undergoing cataract surgery under topical anaesthesia.
      This can be further augmented if the patient is poorly compliant with routine antihypertensive medications or has omitted antihypertensive medication on the day of surgery. This is especially so in hospitals where fasting is mandatory irrespective of the type of anaesthesia utilized.
      Anxiolysis prior to surgery can prevent catecholamine secretion and reduce haemodynamic lability. A simple explanation and reassurance suffices in most cases, but a wide range of drugs, including oral (e.g. diazepam, midazolam, melatonin), i.v. (e.g. midazolam, fentanyl, remifentanil, propofol, ketamine, dexmedetomidine) and intranasal or sublingual (e.g. nifedipine), have been used for this purpose. Notably, benzodiazepines hypnotics and opioids can increase the risks of hypotension, bradycardia, and respiratory and central nervous system depression.
      Many centres resort to acute treatment of perioperative hypertension to avoid cancellation, maintain effective use of the operating theatre space and other logistical reasons. Blood pressure lowering drugs, such as labetolol, esmolol, nicardipine, nifedipine, clevipidine and fenoldopam, can lower blood pressure and overcome the adverse haemodynamic effects, but caution is required in administering potent drugs such as hydralazine because of its prolonged and unpredictable effects as well as nitroprusside and nitroglycerine because of higher risks of overshoot (i.e. hypotension).
      • Rodriguez MA
      • Kumar SK
      • De Caro M
      Hypertensive crisis.
      There is a tendency to overestimate the benefit and underestimate the risk of acute blood pressure reduction. Overzealous attempts to prevent and/or treat hypertension can cause an overshoot with unintentional hypotension, which in turn might necessitate the use of vasopressors. The primary aim of blood pressure management should be to prevent labile haemodynamics rather than target an arbitrary predetermined blood pressure. Acute normalization of preoperative hypertension could increase risks as this increases drug interactions with anaesthetic and analgesic drugs, and in turn leads to hypotension and ischaemic organ injury. Treatment of temporary hypertension should focus on using temporary measures.
      Long-term blood pressure treatment has been shown to reduce morbidity and mortality. The same may not be true for short-term perioperative hypertension management during cataract surgery under loco-regional anaesthesia, as it is associated with a low risk of adverse outcomes. In this context, Grades 1 and 2 hypertension may be perceived as a ‘fishbone stuck in the throat,’ but upon further interrogation, may not be a major concern. Current evidence does not permit us to know whether physiological raised blood pressure translates to a material difference in patient important morbidity or mortality outcomes. Until better evidence proves otherwise, patients without severe hypertension should proceed with elective cataract surgery with intraoperative mean blood pressure kept within 20% of baseline as good clinical practice. The eventual decision to defer or proceed with elective cataract surgery must take into account local guidelines, as well as patient-specific, as well as procedure-specific considerations.

      Authors' contributions

      All authors made substantial contribution to the conception and design of the editorial, drafting the article and revising it critically, final approval of the version to be published and agree to be accountable for all aspects of the work, thereby ensuring that questions relating to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

      Declarations of interest

      None declared.

      Funding

      None.

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