Integrating mind and physiology: Bridging psychophysiology and preoperative care in vascular surgery

Abstract

In this editorial, we comment on the article by Salem et al published in the recent issue of the World Journal of Psychiatry. Patients undergoing vascular surgery face a substantial psychological burden due to the chronic and severe nature of their conditions, often involving the threat of limb loss or life-threatening complications. Up to 40% experience significant preoperative anxiety, which has been increasingly linked to perioperative hemodynamic instability, anesthetic challenges, postoperative pain, wound complications, and delayed clinical progress. Anxiety-driven sympathetic activation elevates blood pressure, heart rate, and vascular resistance, while sustained stress responses impair endothelial function, immune regulation, and tissue repair. Personality traits, including neuroticism and conscientiousness, may further modulate stress reactivity, influencing postoperative outcomes. Although literature identified through PubMed, EMBASE, and Scopus underscores the importance of psychological factors, integration of psychological assessment into standard perioperative protocols in vascular surgery remains limited. This editorial reviewed current evidence connecting psychological vulnerability with perioperative physiology and outcomes, and proposes a structured, patient-centered framework for implementing psychological evaluation and targeted interventions within a holistic, multidisciplinary preoperative care model.

Key Words: Vascular surgery; Preoperative care; Psychological assessment; Anxiety; Emotional resilience; Patient-centered care; Perioperative optimization

Core Tip: Despite the well-established impact of psychological stress during the preoperative period on vascular surgery outcomes, it remains largely overlooked in everyday clinical practice. Psychological conditions such as anxiety, emotional instability, and maladaptive coping adversely affect hemodynamics, impair wound healing, and prolong recovery, whereas emotional stability and conscientiousness enhance adherence, patient satisfaction, and resilience. Integrating systematic psychological assessment, brief interventions, and strategies such as mindfulness or cognitive-behavioral therapy into preoperative care may provide a practical, low-cost approach to improving perioperative outcomes. This article emphasizes a holistic “mind-vessel” perspective, highlighting the translational potential of combining physiological and psychological optimization in vascular surgery.

This editorial refers to “Preoperative anxiety among patients and its correlation with their personality type and pain: A cross-sectional study” by Salem et al, 2026; https://doi.org/10.5498/wjp.v16.i1.112129.

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INTRODUCTION

The unseen burden of the vascular patient

Pathologies relevant to vascular surgery include complex, high-risk conditions such as peripheral arterial disease (PAD), abdominal aortic aneurysm (AAA), and critical limb ischemia (CLI). Those diseases are marked by chronic ischemia, progressive tissue damage, and significant morbidity[1-3] that not only may endanger survival but also profoundly affect patients’ psychological equilibrium. Moreover, chronic pain, reduced mobility, and fear of limb loss that are frequently observed in this cohort of patients, frequently lead to anxiety, depressive symptoms, and emotional exhaustion[3]. Despite this, perioperative optimization in vascular surgery remains mainly focused on physiological stability specifically on cardiac, renal and metabolic optimization through a multilevel approach that includes pharmacological, exercise, and nutritional interventions, while systematic assessment of psychological health is rarely implemented and often treated as secondary rather than integral to preoperative care.

This neglect persists even though preoperative anxiety has been strongly identified as an independent predictor of perioperative complications and delayed recovery[4,5]. Moreover, elevated preoperative psychological distress has been linked to an increased risk of postoperative pulmonary complications as well as new-onset mental health conditions[6]. Preoperative depression or depressive symptoms is associated with worse postoperative recovery. In the largest and most up-to-date meta-analysis, including 57 studies (overall approximately 27.7 million patients), patients with preoperative depression had a mean postoperative hospital stay 0.98 days longer than those without: 95% confidence interval (CI) 0.35 days to 1.62 days[7]. The psychiatric burden may also affect the postoperative period. In a prospective study of patients undergoing open AAA repair or aorto-femoral bypass, pre-operative depression or depressive symptoms are associated with worse postoperative recovery: About 18% of patients developed a new psychiatric disorder within 3 months to 9 months after surgery: Versus approximately 4% in those receiving endovascular repair or non-surgical treatment; odds ratio (OR) = 6.0, 95%CI: 1.6-22.1[8]. Elevated presurgical cortisol levels were associated with both baseline and 9 months psychiatric symptoms, suggesting a possible neuro-endocrine vulnerability[8], highlighting that the psychological impact of surgery continues well beyond the immediate perioperative period. Baseline mental health score whenever low, especially if associated with limited social and familiar support, may also be linked to increased unplanned 30 days readmissions, with hazard ratios ranging from approximately 1.5 to 2.0[9].

Despite the recent European Society for Vascular Surgery (ESVS) guidelines underscore the complexity of decision-making in AAA and PAD management, emphasizing multidisciplinary care and patient-centered strategies[10-12], in those documents still little to none attention to psychological readiness or emotional resilience are given, making the vascular patient paradoxically optimized in hemodynamic and metabolic terms, yet often unprepared psychologically and creating a mismatch between what is suggested to be measured for preoperative patients’ optimization and what could ultimately influence both the intraoperative and postoperative recovery. Therefore, integrating psychological screening and targeted interventions into preoperative assessment could represent a critical step toward precision perioperative medicine, a model that accounts for both physiological and psycho-behavioral determinants of outcome and more accurately reflects the lived experience and recovery needs of vascular surgery patients.

The psychophysiological interface

Psychological distress and surgical outcome are mediated by several neuroendocrine, autonomic, and inflammatory mechanisms. These interconnected systems translate emotional stress into quantifiable physiological responses that can directly influence vascular tone, endothelial function, and wound repair and potentially influence surgical outcomes.

Autonomic activation and hemodynamic consequences: Preoperative anxiety is frequently encountered among patients presenting for vascular procedures, and its physiological expression emerges within seconds. Sensory and cognitive inputs integrated within the amygdala, hypothalamus, and locus coeruleus precipitate rapid activation of the sympathetic adrenal medullary axis, yielding an acute rise in circulating epinephrine and norepinephrine[13]. These catecholamines bind to α- and β-adrenergic receptors, producing the characteristic cardiovascular responses: Increased chronotropy and inotropy, heightened vascular tone, and corresponding elevations in arterial pressure[14]. Although such perturbations are generally tolerated under normal conditions, even minor fluctuations in blood pressure or cardiac rhythm may complicate anesthetic management and have been associated with less favorable perioperative outcomes[15-17]. This vulnerability is particularly relevant in vascular surgery, where patients often exhibit impaired vascular reserve due to longstanding atherosclerosis, endothelial dysfunction, or arterial stiffness[18]. Excess sympathetic drive further augments platelet activation and oxidative stress, mechanisms that may exacerbate ischemia, compromise graft performance, and impede early wound healing[19]. Importantly, this cascade is initiated long before surgical incision, underscoring the rapidity with which psychological threat cues are translated into hemodynamic activation and highlighting the intimate interdependence between emotional state and cardiovascular physiology[20].

Neuroendocrine modulation - the role of cortisol and glucocorticoids: Sympathetic arousal is paralleled by activation of the hypothalamic pituitary adrenal axis. Hypothalamic secretion of corticotropin releasing hormone stimulates adrenocorticotropic hormone release from the anterior pituitary, subsequently driving cortisol production within the adrenal cortex[21-23]. Transient elevations in cortisol support metabolic stability, enhancing glucose availability and moderating excessive inflammation. However, persistent psychological stress or sustained anticipatory anxiety disrupts these adaptive functions. Moreover, prolonged cortisol elevation increases endothelial oxidative stress, impairs nitric oxide-mediated vasodilation, and destabilizes vascular homeostasis[24]. Disturbances in cortisol’s circadian rhythm diminish immune coordination and promote pro-inflammatory and atherogenic pathways[25]. At the tissue level, chronic glucocorticoid exposure induces a catabolic state characterized by enhanced gluconeogenesis, accelerated protein turnover, and reduced insulin sensitivity, thereby limiting the metabolic resources necessary for wound repair and angiogenesis[26-28]. These constraints have direct clinical relevance: Elevated cortisol slows fibroblast and keratinocyte proliferation, disrupts extracellular-matrix assembly, and delays both granulation tissue formation potentially impairing epithelial closure[29,30]. Dysregulated activity of matrix metalloproteinases and tissue inhibitors of metalloproteinases may further compromise structural integrity during healing[31,32]. In patients already experiencing chronic ischemia or microvascular impairment, the cumulative impact of sustained cortisol elevation may significantly shape postoperative trajectories, often in ways appreciated only retrospectively[33]. Ultimately, sympathetic excitation, cortisol excess, and metabolic strain operate synergistically, forming a biologically coherent stress milieu relevant to perioperative risk[34].

Vascular dysfunction and inflammation: The combined autonomic and neuroendocrine responses manifest most prominently within the vascular system. Endothelial cells exposed to elevated catecholamines and glucocorticoids exhibit reduced nitric oxide bioavailability, increased expression of adhesion molecules, and heightened levels of inflammatory mediators including interleukin-6, tumor necrosis factor-α, and C-reactive protein[35]. These disturbances propagate throughout the microcirculation, constricting perfusion and diminishing oxygen delivery to tissues that often exist near the threshold of adequate supply. Clinically, the consequences include delayed wound repair, impaired antimicrobial defense, and increased susceptibility to postoperative complications, including graft dysfunction or wound infection[36]. For patients with peripheral artery disease or advanced atherosclerosis, stress-induced vascular perturbations may represent the pivotal factor distinguishing an uncomplicated recovery from a prolonged or unstable one. Moreover, this relationship is bidirectional: Delayed healing, postoperative discomfort, or unexpected complications may amplify anxiety, thereby reinforcing the same physiological circuits that hinder recovery. Despite its clear relevance, this reciprocal stress inflammation healing loop remains insufficiently addressed in conventional perioperative practice. Recognizing the intersection of psychological stress and vascular biology supports a more integrative, patient-centered approach, acknowledging emotional state as a meaningful determinant of surgical risk rather than a peripheral consideration (Figure 1).

Figure 1 Mind-vessel interface: Neuroendocrine, autonomic, and inflammatory pathways. BP: Blood pressure; HPA: Hypothalamic pituitary adrenal.

EVIDENCE LANDSCAPE: PSYCHOLOGICAL PREDICTORS OF SURGICAL OUTCOMES

Preoperative psychological states showed a measurable influence on surgical recovery across different surgical disciplines positioning psychological assessment as a clinically relevant component rather than an additional consideration[37]. Preoperative anxiety is a common phenomenon in surgical patients and has measurable effects on perioperative outcomes. In a meta-analysis of 24 cohorts of adult patients undergoing elective surgery, Shebl et al[38] reported that higher preoperative anxiety was associated with increased anesthetic requirements [standardized mean difference (SMD) = 0.67; 95%CI: 0.32-1.01] and greater postoperative analgesic consumption (SMD = 0.89; 95%CI: 0.65-1.12). Anxiety was also linked to delayed postoperative recovery: Patients with higher anxiety required longer time to reach a Modified Aldrete Score of 9 (SMD = 0.79; 95%CI: 0.50-1.07) and had longer extubation times (SMD = 0.89; 95%CI: 0.58-1.21)[38]. Although no statistically significant pooled effect was found on self-reported postoperative pain, the substantial heterogeneity across studies suggests that anxiety may still influence pain perception in specific surgical contexts or patient subgroups. These findings reinforce the importance of assessing and managing preoperative anxiety, particularly in high-risk vascular surgery patients, where psychological factors may compound perioperative risk and recovery trajectories. Complementing these findings, a large prospective cohort study of 1168 patients by Aminpour et al[39] used ecological momentary assessment over 30 days postoperatively to quantify changes in anxiety and depression. The study found that preoperative Patient-Reported Outcomes Measurement Information System-Anxiety scores were strongly associated with postoperative worsening anxiety, with adjusted odds ratios of 2.48 for mild symptoms and 2.22 for moderate to severe symptoms. Preoperative pain also independently predicted worsening anxiety. Similarly, preoperative Patient-Reported Outcomes Measurement Information System-Depression scores predicted postoperative worsening depression. Notably, a self-reported history of anxiety or depression did not independently predict postoperative worsening of either condition. These results highlight that active preoperative symptom burden, rather than simple psychiatric history, identifies patients at risk for postoperative psychological deterioration, which may contribute to worse pain, delayed recovery, and functional impairment[39]. Supporting a cascading relationship between emotional distress and functional outcomes.

Salem et al[40] published a significant paper in World Journal of Psychiatry, pointing out that moving beyond transient anxiety, trait personality has also been robustly linked to outcomes. The most widely accepted framework in contemporary personality psychology is the five-factor model, which characterizes stable interindividual differences across five core dimensions: Openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. These traits can capture enduring patterns of cognition, emotion, and behavior, and have demonstrated predictive value for health behaviors, stress responsivity, and postoperative recovery trajectories[41,42].

In a prospective study of 78 older adults with hip fracture, Shin et al[43] found that, after multivariate logistic regression, higher neuroticism (measured preoperatively) was independently associated with postoperative delirium, while higher conscientiousness conferred a protective effect. Specifically, these personality traits persisted in the final predictive model alongside lower Mini-Mental State Examination scores and use of regional anesthesia demonstrating that personality traits can exert clinically meaningful effects even in acute surgical contexts. Similarly, in a cohort of 65 patients surgically treated for proximal humerus fractures, neuroticism scores measured with the Eysenck Personality Questionnaire short version, were negatively correlated with functional recovery: Constant Shoulder Score r = -0.28 (P = 0.23), Oxford Shoulder Score r = -0.46, and positively correlated with disability on the QuickDASH (r = +0.30; P = 0.17) indicating that trait emotional reactivity can shape rehabilitation trajectories[44].

Furthermore, personality dimensions beyond the five-factor model also matter. Classic typologies in psycho-cardiology describe broader personality profiles that influence how individuals respond to surgical stress and illness[45]. Offering clinicians an additional framework for anticipating behavioral and physiological responses during the perioperative period (Table 1).

Table 1 Summary of personality types and stress responsivity.

Personality type	Core characteristics	Stress responsivity/physiological pattern	Clinical relevance
Type A	Competitiveness, time urgency, and hostility	Heightened cardiovascular reactivity; increased sympathetic activation	Linked with higher cardiovascular risk and stress-related complications
Type B	Relaxed, patient, and low urgency	Lower stress responsivity; more adaptive physiological responses	Generally protective profile
Type C	Emotional suppression, compliance, and conflict avoidance	Inefficient emotional processing; internalized stress	Influences coping style and physiological stress burden
Type D	Negative affectivity and social inhibition	Maladaptive stress processing; chronic arousal	Associated with poorer cardiovascular outcomes; relevant perioperatively

A recent prospective cohort of 200 elective spine surgery patients demonstrated that type-D personality (characterized by negative affectivity and social inhibition) was present in 30% of patients and was associated with higher postoperative pain with a mean postoperative pain score (VAS) of 4.0 in the type-D group vs 2.0 in the non-type-D group at 12 months (β = 0.34, 95%CI: 0.18-0.52, P = 0.004, Cohen’s d = 0.61)[46].

In the study by Nilsson et al[47], in daysurgery populations (n = 260) has also reported that conscientiousness is inversely correlated with poorer postoperative recovery. Changes in the physical interdependence subscale of the Quality of Recovery-40 between postoperative days 7 and days 14 correlated negatively with conscientiousness (r = -0.17, P = 0.028-0.030). These findings suggest effect sizes that, while modest, are consistent and reproducible across settings, indicating that personality exerts a steady, measurable influence on recovery trajectories.

Evidence from vascular surgery cohorts further reinforces these associations. Patients with high preoperative anxiety undergoing carotid surgery had a significantly greater incidence of the composite endpoint (stroke, myocardial infarction, or death) compared with those with lower anxiety (10.5% vs approximately 0%, P = 0.02)[48]. Moreover, depressive symptoms confer measurable perioperative risk: Vascular patients with preexisting depression experience a 38% longer hospital stay (incidence rate ratio = 1.38) and an 82% higher likelihood of unplanned 30 days readmission, underscoring the prognostic significance of baseline emotional status[49]. Furthermore, postoperative psychological burden extends beyond formal psychiatric diagnoses: In a cohort of 257 patients undergoing lowerextremity revascularization for symptomatic PAD, 35% had pre-operative depression, which was associated with a significantly increased risk of a composite endpoint of death or major adverse cardiovascular events [heart rate (HR) = 2.05; P < 0.0001]. Specifically, depression predicted progression of contralateral PAD (HR = 2.20; P = 0.009) and coronary heart disease events (HR = 2.31; P = 0.005), although it was not associated with cerebrovascular events or all-cause mortality, highlighting the prognostic relevance of baseline emotional health for cardiovascular outcomes beyond the treated limb[50]. Lower baseline mental health scores and limited social support were independently associated with a substantially higher risk of 30 days unplanned readmission with a reported hazard ratio between 1.5-2 in a large vascular/general surgery cohort, underscoring the prognostic significance of psychosocial resilience[9]. Collectively, these quantitative findings demonstrate that psychological disposition exerts a direct, measurable influence on perioperative physiology and behavior, shaping recovery trajectories in patients already burdened by endothelial dysfunction, chronic ischemia, and limited tissue perfusion[51-53].

These quantitative insights support the conceptual model that personality and anxiety are independent predictors of postoperative trajectories, reinforcing the value of incorporating psychological profiling into perioperative assessment. Despite these advances, methodological heterogeneity persists. Most trials are small, intervention designs vary widely, and few address long-term outcomes such as wound healing, graft patency, or reintervention rates in vascular surgery[54,55]. Leaving important procedure-specific questions unanswered. Additionally, the durability of psychological benefits beyond discharge and cost-effectiveness relative to standard prehabilitation remain incompletely characterized highlighting key gaps that limit large-scale adoption[56].

BRIDGING MIND AND VESSEL: CLINICAL TRANSLATION

Recognizing psychological distress as an independent perioperative risk factor reframes preoperative assessment: Emotional states are not ancillary concerns but integral determinants of recovery trajectories and should therefore be evaluated with the same rigor as traditional physiological risks[18]. Therefore, the “mind-vessel” interface represents a clinically actionable target rather than a conceptual abstraction. Integration can occur across three complementary levels: Preoperative screening, perioperative support, and postoperative follow-up allowing psychological care to be woven into the entire surgical pathway.

Preoperative screening and risk stratification

Integrating a structured psychological assessment into the preoperative phase establishes the foundation for a continuous perioperative pathway that will extend into the intraoperative and postoperative periods. Brief, validated tools such as the Hospital Anxiety and Depression Scale (HADS)[57], the short-form State-Trait Anxiety Inventory[58], and concise coping or personality measures can be administered by surgical nursing or anesthesiology staff during routine preoperative visits. These instruments allow rapid identification of anxiety, depressive symptoms, and stress-reactive traits without disrupting clinic workflow.

Patients with elevated scores are at higher risk for maladaptive physiologic responses, impaired pain modulation, and reduced perioperative resilience. As with frailty or nutritional assessments used to guide prehabilitation, psychological metrics inform early triage toward tailored interventions. When combined with conventional vascular surgery risk tools (e.g., Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, Revised Cardiac Risk Index) and nutritional screens (e.g., Malnutrition Universal Screening Tool, Nutritional Risk Screening 2002), they contribute to a unified bio-psychological risk model that captures both physiologic and emotional determinants of surgical vulnerability[59].

To maintain efficiency, questionnaires can be followed by a brief semi-structured interview embedded within routine history-taking. This allows clinicians to interpret scores in context, explore coping strategies, and address procedure-specific concerns such as fear of limb loss or inadequate social support. This two-step process ensures that psychological vulnerability is recognized before surgery, enabling anticipatory planning in the subsequent intraoperative and postoperative phases.

Patients who exceed predefined thresholds or raise concerns during interview can be automatically flagged in the electronic medical record for targeted evaluation by a psychologist or liaison psychiatrist. Specialist review clarifies whether distress is transient or clinically significant and provides personalized recommendations that can be integrated into intraoperative management (e.g., anxiolytic strategies) and postoperative care (e.g., enhanced support for pain or mobilization).

Finally, psychological findings are incorporated directly into the comprehensive preoperative evaluation. Positioning emotional and behavioral factors alongside physiologic and nutritional indices establishes psychological profiling as a core component of surgical readiness. This multidimensional risk characterization enables surgeons, anesthesiologists, and perioperative teams to anticipate patient-specific challenges and effectively link preoperative screening to targeted intraoperative strategies and postoperative recovery pathways.

Perioperative programs and tailored psychological interventions

Effective perioperative psychological care requires structured collaboration among surgeons, anesthesiologists, and psychiatrists[54,60,61]. Within this multidisciplinary framework, patient-specific risk profiles generated during preoperative screening guide the creation of individualized stress-management plans that align behavioral strategies with surgical and anesthetic considerations. Embedding psychological care into routine perioperative planning rather than treating it as an adjunct supports physiological stability, enhances emotional preparedness, and ensures that interventions are proportional to the severity of anxiety, depressive symptoms, or maladaptive coping patterns identified preoperatively.

Early evidence indicates that integrated multidisciplinary programs improve patient satisfaction (reported increases of 70%-85%), reduce perioperative anxiety by 25%-40%, and may shorten hospitalization by 0.5 day to 1.2 days, suggesting meaningful clinical and operational benefits[62,63]. To deliver these effects efficiently, interventions can be organized along a continuum of intensity, allowing clinicians to match therapeutic modalities to specific psychological needs.

Low-intensity or brief interventions are suitable for patients with mild-to-moderate psychological vulnerability. Strategies such as single-session guided relaxation, preoperative mindfulness exercises, and app-based stress-reduction modules can be implemented during standard clinic visits or via telehealth[60-62]. Randomized trials show reductions in anxiety of 20%-35% and attenuation of cortisol and sympathetic activation within 24 hours to 48 hours[64,65]. Their brief duration (< 15 minutes) and scalability make them practical in high-throughput vascular surgery settings.

Structured behavioral programs are indicated for patients with moderate-to-high psychological risk or maladaptive coping identified during screening. Cognitive-behavioral therapy, mindfulness-based stress reduction, and multimodal psychoprophylaxis programs have been associated with 30% to 50% reductions in preoperative anxiety, improved postoperative functional recovery (e.g., 15% to 25% greater ambulation by postoperative day 3), and modulation of inflammatory markers such as C-reactive protein and interleukin-6[64,66-68].

Environment focused strategies complement patient centered interventions by optimizing external factors that influence perioperative stress responses. Structured preoperative briefings, consistent patient education, and music therapy reduce uncertainty-induced autonomic hyperactivation, improving heart rate variability indices by 10% to 15% and promoting more predictable hemodynamic patterns during induction and early recovery[69-71].

Collectively, this tiered and multidisciplinary approach ensures that perioperative psychological interventions are matched to patient risk, seamlessly integrated into workflow, and dynamically adapted across the perioperative continuum. Beyond mitigating distress, these coordinated strategies improve adherence, enhance patient experience, and contribute to favorable surgical outcomes, including lower complication rates and faster functional recovery[64]. Psychological care thus becomes a fundamental component of high-quality vascular surgery, complementing intraoperative and postoperative optimization strategies described in subsequent sections.

Postoperative follow-up: Structured monitoring and risk-adapted pathways

Postoperative management in vascular surgery benefits from a structured, risk-adapted framework that integrates psychological, functional, and physiological parameters into routine surveillance. Patients undergoing vascular interventions often present with pre-existing vascular fragility, autonomic dysregulation, and heightened inflammatory responsiveness. Accordingly, postoperative follow-up should extend beyond technical assessment of the surgical site to include monitoring of emotional state, cognitive function, and overall recovery capacity. A systematic approach facilitates early recognition of destabilizing factors, such as escalating stress responses, impaired coping, or functional stagnation that may influence wound healing, graft performance, and adherence to rehabilitation[38].

Risk stratification and follow-up scheduling

Risk categorization should be initiated early and revisited throughout recovery, incorporating preoperative psychological screening, intraoperative events, and immediate postoperative clinical status[39]. This structure enables clinicians to tailor follow-up intensity according to the patient’s evolving needs: (1) Low-risk: Patients with minimal psychological vulnerability and an uncomplicated postoperative course; (2) Follow-up: Routine ward assessments with post-discharge telehealth or phone reviews at 1 week to 2 weeks and 4 weeks to 6 weeks; (3) Monitoring: Brief validated questionnaires (HADS, Perceived Stress Scale) and concise interviews to detect subtle shifts in mood or coping; (4) Moderate-risk: Patients experiencing moderate psychological distress, pre-existing psychiatric conditions, or postoperative complications affecting mobility or daily functioning; (5) Follow-up: Scheduled in-person or telehealth assessments at 1 week, 2 weeks to 3 weeks, and 6 weeks; (6) Monitoring: Combination of validated psychological scales, semi-structured interviews, and functional assessments such as mobility testing and evaluation of independence in activities of daily living, guiding individualized behavioral or supportive interventions; (7) High-risk: Patients with severe anxiety, depression, maladaptive coping styles, or complex medical/surgical recovery requiring intensified support; (8) Follow-up: Evaluations every 2 days to 3 days while hospitalized, with weekly outpatient visits during the first postoperative month and biweekly or monthly thereafter as stability improves; and (9) Monitoring: Comprehensive psychological evaluation (HADS, State-Trait Anxiety Inventory), structured functional assessments, and regular semi-structured interviews. Multidisciplinary involvement allows timely adjustment of psychological, behavioral, and pharmacologic strategies[43].

Methods and tools for follow-up

Effective postoperative monitoring requires coordinated use of clinical evaluation, digital tools, and functional assessment. In-person follow-up through ward rounds and specialized vascular clinics enables direct appraisal of wound progression, vascular integrity, and overall recovery. Digital platforms and remote monitoring enhance longitudinal tracking, providing real-time data on mood, stress reactivity, sleep patterns, and functional milestones, and generating alerts when concerning trends arise[44].

Functional markers, including early mobilization, quality of gait, endurance, pain burden, and independence in basic tasks, serve as sensitive indicators of both physical and psychological recovery. Their systematic documentation enables clinicians to correlate emotional status with physiologic progression, supporting timely adjustment of rehabilitation intensity, analgesic strategies, or psychosocial interventions. Integration of psychological and functional data within electronic medical records (EMRs) further enhances continuity of care by generating automated notifications for high-risk patients, streamlining communication across vascular surgery, anesthesia, mental health, and rehabilitation teams, and ensuring that early warning signs translate into actionable clinical responses[46].

Dynamic and personalized follow-up

Postoperative trajectories in vascular patients often fluctuate based on pain control, mobility restoration, vascular perfusion, and psychosocial stability. Follow-up pathways must therefore remain flexible. Patients demonstrating steady improvement may transition to less intensive monitoring, whereas emerging symptoms, such as increasing anxiety, disrupted sleep, functional setbacks, or escalating pain, warrant immediate intensification of surveillance[47]. Personalized postoperative follow-up schedules should account for contextual psychosocial factors, including social support, cognitive function, transportation barriers, and the capacity for home-based rehabilitation, as these factors have been shown to independently predict unplanned 30 days readmission after surgery[9].

Outcome integration and quality assurance

A structured, risk-based postoperative framework facilitates systematic evaluation of psychological distress, functional limitations, medication adherence, and participation in rehabilitation programs. Tailoring follow-up intensity to individual recovery profiles allows clinicians to detect deviations early, optimize wound and graft surveillance, refine pain management, and support behavioral readiness for rehabilitation. Integrating psychological and functional monitoring into routine postoperative workflows promotes scientifically grounded, proactive, and patient-centered care, ultimately improving complication rates, enhancing mobility recovery, and supporting patient-reported quality of life[7].

FUTURE PERSPECTIVES FOR INTEGRATION INTO CLINICAL WORKFLOW

Future perioperative models in vascular surgery will likely rely on structured, technology-enabled systems capable of detecting psychological vulnerability early and responding with timely, low-intensity interventions that integrate seamlessly into routine care[72]. As digital health tools mature, continuous monitoring of behavioral and physiological indicators, such as sleep quality, daily activity rhythms, and patient-reported stress trajectories, may complement traditional vital signs, creating a more nuanced picture of patients’ perioperative readiness. Incorporating these data into electronic medical records could enable automated risk stratification and prompt clinicians when supportive measures are indicated[73].

Adaptive mobile platforms are expected to play a larger role, offering interactive education, cognitive reframing exercises, and personalized behavioral prompts that adjust according to engagement patterns or micro-fluctuations in reported distress[74]. These tools can support sustained prehabilitation, optimize adherence to postoperative rehabilitation, and reinforce self-efficacy during recovery. Immersive technologies such as virtual reality may further facilitate patient preparation by reducing procedural uncertainty, supporting attentional control, and improving pain-related coping through structured, experiential rehearsal[75].

Beyond patient-facing technologies, workflow innovation will be essential. Embedding short, standardized psychological assessments into preoperative clinics; integrating stress-readiness dashboards into the EMR; and establishing rapid referral pathways to behavioral specialists can help ensure scalability without increasing clinical burden[76]. As health systems move toward value-based care models, interventions that reduce postoperative complications, unplanned readmissions, or prolonged rehabilitation may become increasingly aligned with institutional priorities. The future landscape, therefore, points toward a hybrid model that unites digital innovation with pragmatic implementation strategies to create a predictable, efficient, and patient-centered pathway for psychological optimization.

INTERDISCIPLINARY INTEGRATION INTO STANDARD PRACTICE

Sustained integration of psychological readiness into vascular surgical care requires coordinated contributions from multiple disciplines, with each professional group addressing distinct dimensions of risk and recovery. Surgeons can facilitate early identification of individuals displaying elevated procedural worry, avoidant behavior, or decisional conflict. Anesthesiologists contribute by evaluating how emotional states may interact with anesthetic requirements, perioperative stability, or postoperative analgesic needs. Mental-health professionals can offer targeted, evidence-based interventions that can be delivered efficiently within compressed perioperative timelines[77].

Nursing teams, physical therapists, and rehabilitation specialists are equally central, as they maintain daily patient contact and are often first to detect emerging distress, impaired motivation, or discrepancies between psychological status and functional recovery[78]. Interdisciplinary case discussions, integrated care plans, and shared digital assessments allow psychological concerns to be flagged early and addressed consistently across the perioperative continuum. Such collaboration aligns with contemporary models of complex care delivery, emphasizing anticipatory management, communication fluidity, and distributed responsibility[79].

For institutions, embedding this interdisciplinary approach requires developing standardized training modules on psychological risk factors, creating unified documentation templates within the EMR, and establishing quality indicators that track adherence to psychological readiness pathways. This structure ensures that emotional and behavioral determinants of recovery are treated with the same rigor as traditional physiological metrics, thereby strengthening continuity of care and enhancing the overall therapeutic environment for vascular patients.

CONCLUSION

Psychological readiness is a critical yet underrecognized determinant of perioperative outcomes in vascular surgery. Moving beyond the traditional physiologically centered approach, contemporary evidence supports incorporating brief psychological screening, targeted interventions, and structured follow-up into routine care pathways. These measures allow clinicians to identify vulnerable patients early and address modifiable risk factors that influence recovery trajectories. To progress from conceptual acknowledgment to clinical routine, future work must prioritize high-quality trials that evaluate the efficacy of scalable, low-resource interventions and determine the most effective timing, format, and intensity across diverse patient subgroups. Outcomes of interest should include not only standard surgical metrics but also functional recovery, patient-reported experience, adherence to postoperative rehabilitation, and long-term quality of life. Embedding psychological optimization into the fabric of vascular surgical care represents a logical extension of patient-centered medicine. By integrating emotional, behavioral, and physiological dimensions of perioperative risk, clinicians can support more stable recoveries, reduce preventable complications, and improve the lived experience of patients facing complex vascular interventions. This multidimensional approach aligns with the evolving standards of modern healthcare and offers a meaningful pathway toward more comprehensive, resilient, and effective surgical care.