Routine coronary arteriography before abdominal aortic aneurysm repair

Safety and Necessity of Antiplatelet Therapy on Patients Underwent Endovascular Aortic Repair with Both Stanford Type B Aortic Dissection and Coronary Heart Disease

Background:

Acute aortic dissection is known as the most dangerous aortic disease, with management and prognosis determined as the disruption of the medial layer provoked by intramural bleeding. The objective of this study was to evaluate the safety and necessity of antiplatelet therapy on patients with Stanford Type B aortic dissection (TBAD) who underwent endovascular aortic repair (EVAR).

Methods:

The present study retrospectively analyzed 388 patients with TBAD who underwent EVAR and coronary angiography. The primary outcomes were hemorrhage, death, endoleak, recurrent dissection, myocardial infarction, and cerebral infarction in patients with and without aspirin antiplatelet therapy at 1 month and 12 months.

Results:

Of those 388 patients, 139 (35.8%) patients were treated with aspirin and 249 (64.2%) patients were not treated with aspirin. Patients in the aspirin group were elderly (57.0 ± 10.3 years vs. 52.5 ± 11.9 years, respectively, χ² = 3.812, P < 0.001) and had more hypertension (92.1% vs. 83.9%, respectively, χ² = 5.191, P = 0.023) and diabetes (7.2% vs. 2.8%, respectively, χ² = 4.090, P = 0.043) than in the no-aspirin group. Twelve patients (aspirin group vs. no-aspirin group; 3.6% vs. 2.8%, respectively, χ² = 0.184, P = 0.668) died at 1-month follow-up, while the number was 18 (4.6% vs. 5.0%, respectively, χ² = 0.027, P = 0.870) at 12-month follow-up. Hemorrhage occurred in 1 patient (Bleeding Academic Research Consortium [BARC] Type 2) of the aspirin group, and 3 patients (1 BARC Type 2 and 2 BARC Type 5) in the no-aspirin group at 1-month follow-up (χ² = 0.005, P = 0.944). New hemorrhage occurred in five patients in the no-aspirin group at 12-month follow-up. Three patients in the aspirin group while five patients in the no-aspirin group had recurrent dissection for endoleak at 1-month follow-up (2.3% vs. 2.2%, respectively, χ² = 0.074, P = 0.816). Four patients had new dissection in the no-aspirin group at 12-month follow-up (2.3% vs. 3.8%, respectively, χ² = 0.194, P = 0.660). Each group had one patient with myocardial infarction at 1-month follow-up (0.8% vs. 0.4%, respectively, χ² = 0.102, P = 0.749) and one more patient in the no-aspirin group at 12-month follow-up. No one had cerebral infarction in both groups during the 12-month follow-up. In the percutaneous coronary intervention (PCI) subgroup, 44 (31.7%) patients had taken dual-antiplatelet therapy (DAPT, aspirin + clopidogrel) and the other 95 (68.3%) patients had taken only aspirin. There was no significant difference in hemorrhage (0% vs. 1.1%, respectively, χ² = 0.144, P = 0.704), death (4.8% vs. 4.5%, respectively, χ² = 0.154, P = 0.695), myocardial infarction (2.4% vs. 0%, respectively, χ² = 0.144, P = 0.704), endoleak, and recurrent dissection (0% vs. 3.4%, respectively, χ² = 0.344, P = 0.558) between the two groups at 12-month follow-up.

Conclusions:

The present study indicated that long-term oral low-dose aspirin was safe for patients with both TBAD and coronary heart disease who underwent EVAR. For the patients who underwent both EVAR and PCI, DAPT also showed no increase in hemorrhage, endoleak, recurrent dissection, death, and myocardial infarction.

Role of prophylactic coronary revascularisation in improving cardiovascular outcomes during non-cardiac surgery: A narrative review

Coronary revascularisation has been a topic of debate for over three decades in patients undergoing high-risk non-cardiac surgery. The paradigm shifted from routine coronary angiography toward stress test guided decision-making based on larger randomised trials. However, this paradigm is challenged by relatively newer data where routine coronary angiography and revascularisation is shown to improve perioperative cardiovascular outcomes. We review major studies performed over a long period including more contemporary data with regard to the 2014 American College of Cardiology/American Heart Association as well as 2014 European Society of Cardiology guideline on perioperative cardiovascular evaluation of patients undergoing non-cardiac surgery.

Combined Coronary Artery Bypass Grafting and Abdominal Aortic Aneurysm Repair

The purpose of this paper was to assess the results and feasibility of simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair. Twenty nine patients with a mean age of 65 years underwent simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair between June 1990 and March 2002. All patients had significant coronary artery disease and were considered as indicated for coronary artery bypass grafting. This was performed first in 28 patients and simultaneously with abdominal aortic aneurysm repair in one, with a mean number of grafts of 2.5, a mean aortic cross-clamp time of 40 minutes, and a mean bypass time of 115 minutes. Eight straight and 21 bifurcated grafts were employed. The total operating time averaged 400 minutes. The median postoperative hospital stay was 18 days. One patient died of stroke and mediastinitis, for a mortality rate of 3.5%. This experience suggests that combined coronary artery bypass grafting and abdominal aortic aneurysm repair is both safe and effective.

Frequency of coronary artery disease in patients undergoing peripheral artery disease surgery

The prevalence of coronary artery disease (CAD) in patients with peripheral arterial disease (PAD) varies widely in published reports. This is likely due at least in part to significant differences in how PAD and CAD were both defined and diagnosed. In this report, the investigators describe 78 patients with PAD who underwent preoperative coronary angiography before elective peripheral revascularization and provide a review of published case series. Among the patients included, the number with concomitant CAD varied from 55% in those with lower-extremity stenoses to as high as 80% in those with carotid artery disease. The number of coronary arteries narrowed by ≥ 50% was 1 in 28%, 2 in 24%, and 3 in 19%; 28% did not have any angiographic evidence of CAD. The review of published research resulted in the identification of 19 case series in which a total of 3,969 patients underwent preoperative coronary angiography before elective PAD surgery; in the 2,687 who were described according to the location of the PAD, 55% had ≥ 1 epicardial coronary artery with ≥ 70% diameter narrowing. The highest prevalence of concomitant CAD was in patients with severe carotid artery disease (64%). In conclusion, despite sharing similar risk factors, the prevalence of obstructive CAD in patients with PAD ranges widely and appears to differ across PAD locations. Thus, the decision to perform coronary angiography should be based on indications independent of the planned PAD surgery.

Incidence of cardiovascular events and death after open or endovascular repair of abdominal aortic aneurysm in the randomized EVAR trial 1

BACKGROUND

The aim was to compare rates of myocardial infarction, stroke and cardiovascular death in patients with a large abdominal aortic aneurysm who had endovascular (EVAR) or open repair to determine whether cardiovascular mortality explains the convergence in survival curves after these procedures.

METHODS

Between 1999 and 2004, 1252 patients were randomized to EVAR or open repair in the UK EVAR trial 1. All patients were followed for death, myocardial infarction or stroke until September 2009. Cox regression was used to compare cardiovascular events and deaths between the randomized groups during different time intervals.

RESULTS

Over 5 years of follow-up, a total of 187 first non-fatal or fatal cardiovascular events (98 myocardial infarctions and 89 strokes) and 256 cardiovascular deaths occurred. Although the endovascular group had a lower cardiovascular event rate than the open repair group (2·6 versus 3·2 per 100 person-years respectively) this was not statistically significant (adjusted hazard ratio (HR) 0·83, 95 per cent confidence interval 0·62 to 1·10; P = 0·199). Overall, there was little difference in cardiovascular mortality between the randomized groups (adjusted HR 1·06, 0·83 to 1·36; P = 0·638), but a non-significant excess of cardiovascular deaths was apparent in the endovascular group during the 6-24-month interval (adjusted HR 1·44, 0·79 to 2·62; P = 0·237).

CONCLUSION

Patients who had EVAR appeared to have a lower subsequent cardiovascular event rate during all time intervals. Cardiovascular mortality was similar between the two groups overall, but more cardiovascular deaths in the EVAR group appeared to contribute to the convergence in all-cause mortality during the first 2 years.

Does EVAR alter the rate of cardiovascular events in patients with abdominal aortic aneurysm considered unfit for open repair? Results from the randomised EVAR trial 2

OBJECTIVES

To investigate whether endovascular aneurysm repair (EVAR) influences the rate of cardiovascular events (fatal or non-fatal myocardial infarction or stroke) in patients with abdominal aortic aneurysm (AAA) considered unfit for open repair.

DESIGN

Randomised controlled trial.

MATERIALS

Between 1999 and 2004, 404 patients with large AAA considered unfit for open repair were randomised to EVAR or no surgical intervention across 33 UK hospitals and followed until July 2009.

METHODS

The Customised Probability Index was used to determine fitness for each patient and Cox regression was used to compare time to first cardiovascular event between randomised groups and levels of fitness.

RESULTS

During an average of 2.8 years of follow-up, 67 first cardiovascular events occurred with a non-significantly higher event rate in the EVAR group compared to the no intervention group (6.6 versus 5.1 events per 100 person years); adjusted hazard ratio 1.42 [95% CI 0.87-2.34], p=0.156. There was no evidence to suggest that the hazard ratio between randomised groups changed with level of fitness (p=0.378).

CONCLUSIONS

Cardiovascular event rates were high in these unfit patients and medical therapy was sub-optimal. Events rates were slightly higher in the EVAR group but this was not statistically significant.

Cardiac Medical Therapy among Patients Undergoing Abdominal Aortic Aneurysm Repair

Open abdominal aortic aneurysm (AAA) repair is a common surgical procedure associated with high mortality rates. Our objective was to describe the use of in-hospital cardiac medical therapy among patients undergoing open AAA repair and to examine the effect of perioperative cardiac medical therapy on in-hospital mortality. We examined clinical data and in-hospital medication use among 223 patients who underwent open AAA repair at three North American hospitals, all of which used the Transition resource and cost accounting system. Medication use was described [angiotensin converting enzyme (ACE) inhibitors, aspirin, ss-blockers, and statins] within the cohort at five specific periods of time: presurgery, day of surgery, 1 day after surgery, postsurgery, and discharge. We then performed a matched case-control study where cases were defined as patients who died in-hospital. We compared medication use between cases and controls to assess its impact on in-hospital mortality. Most patients were elderly (mean age 72.5 +/- 9.8 years), 70.4% were male, and in-hospital mortality within the cohort was 10.8%. Medication use in all periods of administration was low. ss-Blocker use was highest among all classes on the day of surgery, with 20.6% of patients undergoing AAA repair receiving the medication. Less than 50% of patients received any of the medications at discharge. After adjusting for baseline differences, perioperative ACE inhibitor use showed a trend toward a protective effect [odds ratio (OR) = 0.09, 95% confidence interval (CI) 0.01-1.31, p = 0.08], and perioperative ss-blocker use was significantly associated with a decrease in mortality (OR = 0.07, 95% CI 0.01-0.87, p = 0.04). Cardiac medical therapy among patients undergoing AAA repair is low throughout all periods of hospitalization. ACE inhibitor and ss-blocker use may be associated with decreased in-hospital mortality.

Contrast-enhanced MR Imaging for Evaluation of Coronary Artery Disease before Elective Repair of Aortic Aneurysm

PURPOSE

To prospectively evaluate the accuracy of first-pass contrast material-enhanced magnetic resonance (MR) imaging during stress and delayed contrast-enhanced MR imaging in the detection of significant coronary artery disease in patients before elective repair of aortic aneurysm.

MATERIALS AND METHODS

The study was approved by the institutional ethics committee, and informed consent was obtained from all patients. MR imaging was performed in 49 patients (42 men and seven women; mean age, 72.2 years; age range, 58-85 years) before the elective repair of atherosclerotic aortic aneurysms. Thirty-two patients had an abdominal aneurysm, 12 had a thoracic aneurysm, and five had a thoracoabdominal aneurysm. First-pass contrast-enhanced MR images were obtained with short-axis sections encompassing the entire left ventricular myocardium in the resting state and during pharmacologic stress. Inversion-recovery-prepared delayed contrast-enhanced MR images were obtained with breath holding to evaluate for the presence of infarction. All patients underwent coronary angiography within 2 weeks of MR imaging, and these findings were used as the standard of reference. The diagnostic results of first-pass contrast-enhanced MR imaging, delayed contrast-enhanced MR imaging, and a combination of both MR imaging methods in the detection of significant coronary artery disease were expressed as sensitivity, specificity, and accuracy.

RESULTS

Coronary angiography depicted a clinically significant stenosis (>70% luminal diameter narrowing) in the coronary artery in 34 of the 49 patients (69%). First-pass contrast-enhanced MR imaging depicted stress-induced hypoenhancement in 27 of those 34 patients (79%). Delayed myocardial enhancement was observed in 17 of the 34 patients (50%). The overall sensitivity of rest-stress first-pass contrast-enhanced MR imaging and delayed contrast-enhanced MR imaging combined in the prediction of at least one coronary artery with significant stenosis was 88% (30 of 34 patients). The specificity and accuracy of MR imaging were 87% (13 of 15 patients) and 88% (43 of 49 patients), respectively.

CONCLUSION

Contrast-enhanced MR imaging had an accuracy of 88% in the detection of significant coronary artery disease in patients with aortic aneurysm.

Coronary and carotid artery disease in patients with degenerative aneurysm of the descending thoracic or thoracoabdominal aorta: prevalence and impact on operative mortality

From January 1, 1995 to July 31, 2000, a total of 133 patients underwent elective surgical treatment for degenerative aneurysm of the descending thoracic (n = 45) or thoracoabdominal (n = 88) aorta. There were 116 men (87%) and 17 women (13%) with a mean age of 66.4 +/- 8.7 years (range, 39 to 84 years). Sixteen patients (12%) died in the immediate postoperative period. Thirteen patients (10%) had already undergone myocardial revascularizaton. Thirty-five patients (26%) presented clinical symptoms of coronary artery disease. Preoperative coronary arteriography was performed in 84 (63%) patients, demonstrating normal findings or clinically insignificant lesions in 48 patients (57%), single-vessel lesions (>70% reduction in diameter) in 19 patients, two-vessel lesions in 12 patients, and three-vessel lesions in 5 patients. On the basis of these findings, myocardial revascularization was performed before aortic repair in 11 patients. The total number of myocardial revascularization procedures in this series was 24 (18%). Four patients had previously undergone a total of 6 carotid endarterectomy procedures. Routine duplex ultrasound demonstrated significant carotid artery lesions in 12 patients (9%). Ten of these patients (8%) underwent carotid endarterectomy. The total number of carotid endarterectomy procedures in this series was 16 in 14 patients. The prevalence of coronary and carotid lesions in patients indicated for elective treatment for degenerative aneurysm of the descending thoracic or thoracoabdominal aorta was similar to that observed in patients presenting degenerative aneurysm of the infrarenal abdominal aorta. Univariate analysis demonstrated that coronary and carotid lesions with or without treatment are a significant risk factor for mortality following surgical repair of degenerative aneurysm of the descending thoracic or thoracoabdominal aorta. This finding suggests that routine preoperative coronary arteriography and duplex ultrasound are warranted.

Outcome after simultaneous abdominal aortic aneurysm repair and aortocoronary bypass

Myocardial infarction remains the leading cause of early and late death after abdominal aortic aneurysm (AAA) repair. Myocardial revascularization is staged either before or concomitant with AAA resection, but results are far from uniform. We retrospectively analyzed our experience with patients who underwent concomitant AAA resection and aortocoronary bypass (ACB) to examine the factors affecting early morbidity/mortality and early results. Forty-two patients (all men; mean age, 67.2 years) underwent simultaneous ACB grafting and AAA repair between 1975 and 1998. All were managed postoperatively in the cardiothoracic intensive care unit (mean stay, 6.1 days). The mean total hospital stay was 17.2 days. Two died in the early postoperative period (4.8%): 1 of sustained myocardial failure following a third ACB, and 1 of coagulopathy after concomitant ACB, aortic valve replacement, and AAA. One patient developed a nonfatal MI on postoperative day 3. The incidence of wound and bleeding complications was higher for patients undergoing both ACB and AAA repair than for patients undergoing AAA resection alone. On follow-up (mean, 10 years; range, 7 months to 15 years), only 2 of 10 late deaths were due to cardiovascular causes. We believe that concomitant myocardial revascularization is warranted in select patients requiring elective or urgent AAA resection in order to decrease perioperative risk and improve late survival. Cardiac failure or ischemia during aortic surgery can be prevented by proper perfusion with or without cardiopulmonary bypass. In patients undergoing simultaneous procedures, the increased risk is related to the severity of the vascular and coronary artery disease and not to the combined operations.

Autologous blood donation with recombinant human erythropoietin for abdominal aortic aneurysm surgery

We evaluated the efficacy of autologous blood donation using recombinant human erythropoietin for elective abdominal aortic aneurysm (AAA) surgery regarding postoperative recovery. Twenty-five AAA patients who completed surgery without receiving a homologous blood transfusion were divided into two groups, consisting of a control group (n = 12) who did not bank any autologous blood, and a donation group (n = 13) who did bank more than 800 ml of autologous blood with the use of erythropoietin. The hematocrit (Ht) level of the control group decreased from 41.1% +/- 1.2% before the operation to 36.2% +/- 0.9% just afterwards (P > 0.01). In the donation group, however, the Ht did not change significantly during either the donation period or the perioperative period. The postoperative period before oral food intake and natural defecation were both significantly shorter in the donation group than in the control group. The first day of mobilization was also earlier in the donation group. In conclusion, autologous blood donation using erythropoietin for AAA surgery is therefore considered to promote the early recovery of patients.

Coronary and major vascular disease: aggressive screening and priority-based therapy

It is well know that atherosclerosis can simultaneously affect different vascular subsystems, and patients with diffuse atherosclerosis can be a major management problem both for preoperative evaluation and for intraoperative management. The authors have conducted a prospective study to evaluate the prevalence of coronary artery disease in arteriopathic patients, and vice versa, to assess the effectiveness of aggressive screening together with a priority-based approach. Study 1 consisted of 1,000 consecutive non-emergent patients who were affected by abdominal aortic or carotid disease and were screened for the presence of coronary artery disease before surgery with a newly developed clinical risk assessment. They were stratified into three risk categories with different preoperative evaluation strategies. When coronary artery disease was concomitantly demonstrated in these patients, the choice of surgical method was based on priorities, and the use of combined surgical procedures as required. In study 2, 1,000 consecutive patients that required coronary angiography for suspected coronary artery disease were screened for the presence of carotid or abdominal aortic pathology, directly in the cardiac catheter laboratory during coronary angiography, by obtaining views of the aortic arch and abdominal aorta. Surgical approaches paralleled those of study 1. The results for study 1 showed that 720 patients (72%) were affected by abdominal aortic disease, 238 (24%) by carotid disease and 42 (4%) by both pathologies. Significant coronary artery disease was found in 152 patients (15%), of these 123 (81.5%) were affected by abdominal aortic disease and 29 (18.5%) by carotid artery disease. Abdominal aortic surgery was performed directly or after myocardial revascularization, with an overall mortality rate of 4/718 (0.6%), and a perioperative myocardial infarction rate of 10/718 (1.4%). For patients with carotid artery disease, the completed screening and possible therapy for coronary artery disease resulted in an in-hospital mortality rate of 2/238 (0.8%), and a perioperative myocardial infarction rate of 2/238 (0.8%). There were no significant differences in these rates between patients with or without coronary artery disease. Results for study 2 showed that of the 1000 consecutive patients enrolled for suspicion of coronary artery disease, 767 (77%) were affected by significant coronary artery disease. Among these, 38 (4.9%) had a surgically correctable aortic disease and 31 (4%) a surgically correctable carotid disease, which was monolateral and bilateral in 22 (74%) and nine (26%) patients, respectively, and four (0.5%) were diagnosed with both pathologies. These arteriopathic patients were treated for their coronary and vascular disease with no in-hospital mortality nor perioperative myocardial infarction. In patients with multiple vascular involvement, both coronary and vascular surgery can be performed with low risk when aggressive screening and priority-based therapy are adopted.

Cardiac assessment with thallium scanning prior to aortic aneurysm repair

Coronary artery disease occurs commonly in patients with aortic aneurysms and is a major cause of morbidity and mortality. The role of screening and intervention for cardiac disease prior to aneurysm repair is controversial. The outcome after cardiac screening with thallium scanning and/or angiography in 102 consecutive patients undergoing aortic aneurysm repair was documented. Significant coronary artery disease was found in 34 (33%) patients and two patients had either coronary artery bypass or angioplasty prior to aneurysm repair. There was no cardiac mortality after aneurysm repair and the overall mortality on an intention-to-treat basis was 2%. There was good correlation between prior history of cardiac events, electrocardiography (ECG) and the results of screening with thallium scanning and angiography. There was no correlation between cardiac history, ECG and the incidence of cardiac events in the postoperative period. Significant coronary artery disease was found in 33% of patients without a cardiac history or abnormal ECG. Cardiac screening with thallium scanning confirmed a high incidence of significant coronary disease in patients with aortic aneurysm. In this study, cardiac intervention followed by expedient aneurysm repair in 20 patients was associated with zero mortality. The short-term benefit of such a policy is difficult to prove and its main advantage may be better long-term survival.

Is preoperative cardiac evaluation for abdominal aortic aneurysm repair necessary?

PURPOSE

It is reported that 25% to 50% of patients with abdominal aortic aneurysms (AAA) have severe coronary artery disease (CAD) and should undergo an aggressive cardiac workup before AAA repair. In contrast, it has been our policy that patients referred for AAA repairs undergo no cardiac testing before surgery.

METHODS

This report reviews the last 113 consecutive patients who underwent elective AAA repair by the senior author using this policy. Seventy-four patients (group A) had only an electrocardiogram before surgery. The remaining 39 patients (group B) were referred having already had additional testing that included a thallium stress test (n = 20), echocardiogram (n = 18), multiple gated acquisition (MUGA) scan (n = 3), cardiac catheterization (n = 8), or some combination of these.

RESULTS

There was no statistical difference between group A and group B with regard to age, sex, tobacco use or history of coronary artery disease, diabetes mellitus, stroke (CVA), hypertension, peripheral vascular disease, or chronic obstructive pulmonary disease. Group B more commonly had a history of myocardial infarction (41% vs 19%, p < 0.03) and congestive heart failure (23% vs 7%, p < 0.03). During surgery there was no significant differences in blood loss, transfusion requirements, or operative times. There were no myocardial infarctions in group A and two (5.1%) in group B, which was not significantly different. Other complications, such as CVA, renal failure, pulmonary failure, pneumonia, wound infection, and hemorrhage, were not significantly different between the two groups. Postoperative hospital stay was not significantly different. There were three deaths in the entire series (2.7%), and only one in group B was cardiac-related in a patient with known end-stage cardiac disease and a symptomatic 8 cm AAA.

CONCLUSIONS

These data indicate that most patients with AAA can safely undergo repair with no cardiac workup and that cardiac workup before AAA repair contributes little information that impacts on treatment or final clinical outcome. We conclude that cardiac testing in preparation for AAA repair is not usually necessary and that intraoperative hemodynamic management may be the most important variable in determining outcome.