Basic data concerning associated coronary disease in peripheral vascular patients

Is General Anesthesia for Peripheral Vascular Surgery Correlated with Impaired Outcome in Patients with Cardiac Comorbidity? A Closer Look into the Nationwide Danish Cohort

OBJECTIVE

General anesthesia (GA) may impair outcome after vascular surgery. The use of anticoagulant medication is often used in patients with cardiac comorbidity. Regional anesthesia (RA) requires planning of discontinuation before neuraxial blockade(s) in this subgroup. This study aimed to describe the effect of anesthesia choice on outcome after vascular surgery in patients with known cardiac comorbidity.

DESIGN

Retrospective cohort study.

SETTING

Danish hospitals.

PARTICIPANTS

6302 patients with known cardiac comorbidity, defined as ischemic heart disease, valve disease, pulmonary vascular disease, heart failure, and cardiac arrhythmias, undergoing lower extremity vascular surgery between 2005 and 2017.

INTERVENTIONS

GA versus RA.

MEASUREMENTS AND MAIN RESULTS

Data were extracted from national registries. GA was defined as anesthesia with mechanical ventilation. Multivariable regression models were used to describe the incidence of postoperative complications as well as 30-day mortality, hypothesizing that better outcomes would be seen after RA. The rate of RA decreased from 48% in 2005 to 20% in 2017. The number of patients with 1 or more complications was 9.7% vs 6.2% (p < 0.001), and 30-day mortality was 6.0% vs 3.4% (p < 0.001) after GA. After adjusting for baseline differences, the odds ratio (OR) was significantly lower for medical complications (cardiac, pulmonary, renal, new dialysis, intensive care unit and other medical complications; OR, 0.97; 95% confidence interval [CI], 0.95-0.98) and 30-day mortality (OR 0.98; 95% CI, 0.97-0.99) after RA.

CONCLUSIONS

RA may be associated with a better outcome than GA after lower extremity vascular surgery in patients with a cardiac comorbidity. Prioritizing RA, despite the inconvenience of discontinuing anticoagulants, may be recommended.

2017 Position Paper of the Italian Society for Cardiovascular Prevention (SIPREC) for an Updated Clinical Management of Hypercholesterolemia and Cardiovascular Risk: Executive Document

The benefits achieved by implementing cardiovascular prevention strategies in terms of reduced incidence of atherosclerotic diseases and mortality are accepted, worldwide. In particular, the clinical management of hypercholesterolemia has a fundamental role for all preventive strategies, both in primary and secondary prevention, at each stage of cardiovascular risk. Since the net clinical benefit of lipid-lowering therapy largely depends on baseline individual cardiovascular risk profile, the assessment of individual risk is essential to establish type and intensity of both preventive and therapeutic strategies. Thus, the real challenge in a setting of clinical practice is not only to identify whom to treat among individuals at low-to-moderate risk, but mostly how much and how long to treat high or very-high risk patients. This manuscript, which reflects concepts and positions that have been published in a more extensive document of the Italian Society for Cardiovascular Prevention (SIPREC), deals with the diagnostic and therapeutic management of patients with dyslipidaemia, with an evidence-based approach adapted and updated from recent guidelines of the European Society of Cardiology and very recent results of randomized clinical trials. The purpose is to suggest a multidimensional and integrated actions aimed at eliminating or minimizing the impact of cardiovascular diseases and their related disabilities and mortality in patients with hypercholesterolemia.

Revascularization vs. Medical Therapy in Stable Ischemic Heart Disease

The keynote COURAGE and BARI-2D trials changed the way the interventional community selects patients for revascularization. What we now consider appropriate, especially for percutaneous coronary intervention, has narrowed significantly in scope compared to previous practice a decade ago. Medical therapy has been shown to be both safe and effective as a primary treatment modality for patients with stable ischemic heart disease on the whole. However, it appears that patients with a heavy ischemic burden may benefit from revascularization, although investigation of this is ongoing. Evidence preliminarily supports this practice with coronary artery bypass grafting, and possibly in specific populations undergoing multivessel intervention with functional assessment of lesion severity during PCI.

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.

Vascular surgery critical care: perioperative cardiac optimization to improve survival

OBJECTIVE

To review the literature on perioperative cardiac management of patients who are scheduled to undergo vascular surgery.

DATA SOURCE

MEDLINE- and PubMed-based review of literature published from 1965 to 2005.

CONCLUSIONS

Perioperative cardiac events (myocardial infarction, heart failure) remain the leading cause of morbidity and mortality in vascular surgery patients. Existing guidelines allow physicians to cost-effectively streamline preoperative cardiac risk assessment and stratification. Perioperative optimization of volume status and cardiac function and the routine use of perioperative beta-blockers can significantly improve outcomes after major vascular surgery. Perioperative addition of statins to beta-blockers in high-risk patients undergoing vascular surgery merits further evaluation. Preoperative coronary revascularization should be restricted to patients with unstable cardiac symptoms.

Simultaneous operation of ischemic heart disease, abdominal aortic aneurysm, and rectal cancer

A 68-year-old man with ischemic heart disease, abdominal aortic aneurysm, and rectal cancer was referred. Coronary angiography indicated triple-vessel disease with jeopardized collaterals, and dipyridamole myocardial scintigraphy disclosed no viability in the inferior, posterior, and lateral walls. Abdominal computed tomography scanning revealed an infrarenal abdominal aortic aneurysm, 65 mm in diameter, with an expanding rate of 8 mm/year. Barium enema revealed stenosis 4 cm in length 5 cm inward from the anal verge, and an endoscopic finding was ulcerated type tumor with a clear margin and circumferential stenosis. Histological examination of a biopsy specimen revealed adenocarcinoma, and the clinical stage in the Japanese classification of colorectal carcinoma was II according to other examinations. Simultaneous operations were scheduled because of the jeopardized collaterals of the coronary arteries, rapid expansion of the aneurysm, and subileus due to the cancer. The patient underwent simultaneous off-pump coronary artery bypass grafting to the left anterior descending artery with the in situ internal thoracic artery through a median sternotomy, abdominal aortic aneurysm repair with a tube graft through a median laparotomy, and the Miles' operation with total mesorectal excision. Although infection of the perineal wound was postoperatively recognized, it remained local and was healed with irrigation only. The patient is doing well 12 months after the operation, without myocardial ischemic symptoms or recurrence of the cancer.

Relation between platelet microaggregates and ankle brachial index in patients with peripheral arterial disease

INTRODUCTION

Peripheral arterial disease is one of the systemic atherosclerotic diseases, and patients with the disorder are classified in the high risk group of coronary artery disease. A lower ankle brachial index is a frequent finding in peripheral arterial disease. While platelet microaggregates are a significant predictor of adverse clinical outcome in coronary artery disease, the significance of platelet aggregability in peripheral arterial disease has not been elucidated.

MATERIALS AND METHODS

Small platelet aggregates measured using laser-light scattering and ankle brachial index were determined in 42 patients with both coronary artery disease and peripheral arterial disease (peripheral group), 56 patients with only coronary artery disease (coronary group) and 32 patients without both (control group).

RESULTS

The level of small platelet aggregates was increased significantly in the peripheral group (4.3 x 10(4) [range 2.2 x 10(4) to 7.4 x 10(4)]) compared with both the coronary (1.1 x 10(4) [range 0.3 x 10(4) to 5.0 x 10(4)]) and control groups (0.5 x 10(4) [range 0.1 x 10(4) to 0.9 x 10(4)]). There was a significant inverse correlation between log small platelet aggregates and ankle brachial index (n=130, r=-0.422, p<0.001). Multivariate logistic regression analysis revealed that a lower ankle brachial index (<0.90) was an independent determinant of increased levels of small platelet aggregates.

CONCLUSIONS

Platelet aggregability was increased in patients with peripheral arterial disease with the degree of platelet aggregation being closely associated with ankle brachial index. It is possible that this change in platelet activity may be one mechanism to explain why a lower ankle brachial index is a predictor of poor prognosis in patients with peripheral arterial disease.

Intraoperative myocardial ischemia in peripheral vascular surgery: general anesthesia vs combined sciatic and femoral nerve blocks

STUDY OBJECTIVE

The aim of this study was to compare the frequency of intraoperative myocardial ischemia in lower extremity vascular surgery with general anesthesia vs regional anesthesia via combined sciatic and femoral nerve blocks.

DESIGN

This is a prospective, randomized study.

SETTING

This study was set at an academic medical center.

PATIENTS

The study included 50 patients scheduled for elective lower extremity vascular surgery.

INTERVENTIONS

Patients in group 1 received balanced general anesthesia, whereas patients in group 2 received combined sciatic and femoral nerve blocks with 40 mL of 0.375% bupivacaine. Monitoring included a radial artery catheter and multilead, dual-channel electrocardiogram with computerized ST-segment analysis. Blood pressure and heart rate variations were maintained within 10% of preoperative values by adjusting anesthetic depth, fluid replacement, and vasoactive drug dosages.

MEASUREMENTS AND MAIN RESULTS

An ST-segment depression of at least 1 mm or elevation of at least 2 mm lasting for more than 1 minute was considered a significant episode of myocardial ischemia. Intraoperative hemodynamic data and the frequency of significant ST-segment change episodes were recorded. The number of patients with ischemic episodes and the total number of these episodes were lower in group 2 than in group 1 (1 patient vs 7 patients, P = 0.02; and 2 vs 14 episodes, P = 0.04). No significant difference was found between groups 1 and 2 regarding systolic or diastolic arterial pressures, or heart rate.

CONCLUSION

Compared with general anesthesia, combined sciatic and femoral nerve blocks reduce the frequency of intraoperative myocardial ischemia in patients undergoing lower extremity vascular surgery.

Aortic stent-grafting: successful introduction into the combined procedure for coronary artery bypass grafting and aortic aneurysm repair

OBJECTIVES

Coronary artery bypass grafting (CABG) and combined stent-grafting (SG) were evaluated to reduce morbidity and mortality of patients with descending or infrarenal aortic aneurysm.

METHODS

CABG and SG (thoracic n=6, infrarenal n=36) were performed during the same hospitalization in 42 patients (mean age of 73+/-14 years). In 29 patients (mean Euroscore: 9), SG was performed under local anesthesia 9+/-3 days after coronary surgery (simultaneous) and in 13 patients (mean Euroscore: 7) during the same anesthesia (synchronous). In the latter group, 11 out of 13 patients underwent off-pump CABG. All aneurysms were treated by implantation of commercially available self-expanding grafts.

RESULTS

CABG was successful in all, but one patient with left internal mammary artery hypoperfusion syndrome, requiring an additional distal saphenous graft to the left anterior descending coronary artery. SG was uneventful in 98% (41/42 patients). Postoperative computerized tomography showed incomplete sealing in seven patients (17%), but only the two attachment endoleaks had to be treated by one proximal and one distal SG extension. Overall hospital stay for the synchronous repair was 12.5+/-6 days and that of the simultaneous group 17.5+/-7 days. Thirty-day mortality was 5% (2/42) as one patient of the simultaneous group experienced a lethal cerebral embolism during SG and one patient of the synchronous group developed an untreatable infection. In the follow-up of 4 years, there were two vascular reinterventions but no additional procedure-related morbidity or mortality.

CONCLUSIONS

This experience shows that combined CABG and SG of thoracic or infrarenal aortic aneurysm is a safe and less-invasive alternative to the open graft repair, especially in the older patients or patients with severe comorbidities.

Extent and severity of atherosclerotic vascular disease in patients undergoing coronary angiography--the Kuwait Vascular Study

Only a few angiographic studies have correlated the presence and severity of coronary artery disease with atherosclerosis in other arteries. The presence of disease in more than 1 area clearly has important implications on management. One hundred and seventy eight patients had angiographic evaluation of their peripheral arteries and abdominal aorta after routine diagnostic coronary angiography. The extent and severity of vascular disease was correlated with those of coronary artery disease. Of the 178 patients, 73.6% were men (mean age +/- sd was 52.93 +/- 10.12 years). Hypercholesterolemia (59%), systemic hypertension (56.7%) and diabetes mellitus (50.6%) were the major risk factors. Triple-vessel coronary artery disease was present in 48.9%, and 13.5% had normal coronaries. A new atherosclerotic vascular disease score, which reflects the presence and severity of atherosclerotic vascular disease elsewhere, was seen to correlate significantly with the extent of coronary artery disease. Of particular interest was the involvement of the first part of the vertebral artery in 41.6% of patients. The combined involvement of the abdominal aorta, renal artery, and iliac artery segments (together referred to as the lower body segment) was seen almost exclusively in those with 2- or 3-vessel coronary artery disease. Also there was a direct correlation between the extent of coronary artery disease and the score in the lower body segment as opposed to the upper body segment (subclavian, vertebral, and internal mammary arteries). The presence of atherosclerotic vascular disease correlated with the severity of coronary artery disease, particularly in respect to disease in the lower body segment. Thus early detection of such disease in the iliac or femoral arteries has a potential for early diagnosis of significant coronary artery disease.

Critical care of the vascular surgery patient

Providing effective critical care to vascular surgical patients is challenging to the intensivist. These patients often have multiple significant concurrent diseases that need to be adequately managed. A selective policy for identifying patients that need ICU is recommended. Early and smooth restoration to their preoperative physiological homeostasis is crucial. Optimal pain relief, return to normothermia, and adequate intravascular volume replacement are thus key interventions. Epidurals provide excellent analgesia. Vigilant monitoring and decisive therapy of the wide range of complications that may occur in the postoperative is of paramount importance. The level of monitoring should be an extension of that done intraoperatively. Hemorrhage and thrombosis are dreaded sequelae; cardiac morbidity and mortality is significant. Respiratory complications may necessitate prolonged postoperative mechanical ventilation. Careful clinical evaluation is necessary to detect the various neurological complications that may occur. Renal and gastrointestinal complications are potentially lethal. Graft sepsis may occur later. The development of new techniques, such as endovascular repairs of aneurysms, may minimize the need for ICU.

Infrainguinal arterial reconstruction: female gender as risk factor for outcome

OBJECTIVES

the effect of gender on the long-term results of infrainguinal arterial reconstruction are poorly investigated.

METHODS

all patients undergoing infrainguinal arterial reconstruction with an autogenous vein are as 11 years period was prospectively evaluated.

RESULTS

four hundred and fifty reconstructions (292 man, 160 women) were performed as on 416 patients. Thirty-day mortality was 1.1% (n=5). Women were on average older (74 vs 68; p<0.001) and disease was more advanced (81 vs 68%,p =0.013 with stage of critical ischaemia). Primary (58 vs 61%) and primary assisted patency rates (82 vs 84%) were comparable. Limb salvage and survival after 60 months were not different. On multivariate analysis age and stage of the disease were independent variables for patency and survival. Diabetes and gender reached statistical significance as predictors of limb salvage only.

CONCLUSION

age and stage of the disease were independent predictors for patency and survival, diabetes and gender for limb salvage.

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.

Risk of myocardial infarction and angina in patients with severe peripheral vascular disease: predictive role of C-reactive protein

BACKGROUND

Patients undergoing revascularization procedures for peripheral vascular disease (PVD) have a greatly increased risk for coronary artery disease (CAD) that is predicted only partly by clinical data and cardiovascular risk factors. We investigated whether the prognostic assessment in PVD patients could be improved by preoperative measurements of C-reactive protein (CRP).

METHODS AND RESULTS

We assessed clinical and risk factors profiles, Eagle clinical scores, and preoperative CRP serum levels in 51 patients with PVD at Fontaine-Leriche stages II to IV without severe rest ventricular dysfunction or ischemia. During 24 months of follow-up, 17 patients (34%) had fatal (11) or nonfatal (6) myocardial infarction (MI). With univariate logistic regression analysis, only previous history of CAD, Eagle score, and CRP were independently related to MI. At multivariate logistic regression analysis, only CRP values in the upper tertile (<9 mg/L) were significantly associated with MI (P<0.05) and identified 65% of cases.

CONCLUSIONS

The high incidence of MI in patients with PVD severe enough to require revascularization is strongly predicted by preprocedural measurements of serum CRP, independent of previous CAD, Eagle score index, and traditional cardiovascular risk factors. These patients may benefit from therapy modulating the inflammatory response.

Cardiac risk assessment in noncardiac thoracic surgery

Preoperative cardiac risk assessment for noncardiac thoracic surgery is limited by the lack of data specific to this type of surgery, especially prospective, controlled data. However, the value of clinical predictors in determining accurate postoperative cardiac outcomes is a reliable tool. Thus, the approach is similar to traditional cardiac risk assessment for noncardiac surgery. The essential elements of cardiovascular evaluation as it pertains to noncardiac thoracic surgery are reviewed with a specific focus on coronary artery disease, perioperative arrhythmias, and selected topics relevant to noncardiac thoracic surgery. The core recommendations of the clinical guidelines by the American College of Cardiology and American Heart Association are discussed in the context of noncardiac thoracic surgery.

Smoking and obesity are associated with the progression of aortic stenosis

OBJECTIVE

The purpose of the study was to identify clinical predictors of progression of aortic stenosis.

BACKGROUND

The natural history of valvular aortic stenosis includes a latency period followed by an unpredictable progression. Recent investigations have shown an association between risk factors for atherosclerosis and the presence of aortic stenosis. The authors hypothesized that atherosclerosis risk factors are also associated with the progression of aortic stenosis.

METHODS

In a retrospective study, patients with a diagnosis of aortic stenosis were identified by continuous wave Doppler and a follow-up study of at least 6 months. Clinical data at the time of the index echocardiogram were obtained from review of patients' medical records. Independent risk factors for the progression of aortic stenosis were identified by stepwise logistic regression analysis.

RESULTS

One hundred twenty-three patients were identified, and complete data were obtained for 87 patients (mean age, 70.7 +/- 10 years; men, 81%; mean follow-up, 2.54 +/- 1.6 years). The initial gradient was mild in 61% of patients and moderate in 31%. The mean rate of progression was 6.3 +/- 13 mm Hg/year. Mild aortic stenosis in 36% of patients at the time of the index echocardiogram progressed to moderate or severe over an average of 2.9 +/- 2.0 years. Independent clinical factors associated with a progression of 5 mm Hg/year or greater included a history of smoking (relative risk [RR] = 3.06; 95% confidence interval [CI] = 1.09-8.61; p = 0.034) and body mass index (RR = 1.16; 95% CI = 1.03-1.30; p = 0.013). Hypertension, diabetes, cholesterol, age, gender, and coronary artery disease were not independently associated with progression.

CONCLUSIONS

Body mass index and a history of smoking are independent predictors of significant progression of aortic stenosis, defined as > 5 mm Hg/year. The rate of progression of aortic stenosis is variable. However, a substantial number of patients have progression of even initially mild aortic stenosis within a relatively short period of time. The effect of controlling atherosclerosis risk factors on the rate of progression of aortic stenosis remains to be determined.

Epidural analgesia and arterial reconstructive surgery to the leg: effects on fibrinolysis and platelet degranulation

It has been suggested that the incidence of early graft occlusion after arterial reconstructive surgery to the leg may be decreased by epidural analgesia. This effect may be mediated by the suppression of the usual cortisol response to surgery, which results in increased circulating plasminogen activator inhibitor-1 with consequent adverse effects on fibrinolysis. To investigate this and other potential mechanisms, 30 patients undergoing arterial reconstructive surgery to the leg were randomized to receive either general anaesthesia or general anaesthesia plus epidural analgesia. Post-operative analgesia was provided by morphine infusion or epidural analgesia, respectively. Blood samples were collected at 0, 2, 4, 6, 12 and 24 h, and 2, 3 and 5 days and analysed for cortisol, plasminogen activator inhibitor-1 antigen, interleukin-6 and beta thromboglobulin. The incidence of graft-related and systemic complications was recorded for 30 days. Only one patient developed early graft occlusion that required embolectomy and eventually amputation. There were no significant changes from control values in either group of patients in circulating cortisol, plasminogen activator inhibitor-1 and beta thrombogobulin (a marker for platelet degranulation). Interleukin-6 values increased significantly in both groups after 4 h and remained elevated until day 3. There were no significant differences between the groups in any variable measured. We conclude that any effect of epidural analgesia on early graft patency is unlikely to be mediated by fibrinolysis or platetlet degranulation.

Peripheral vascular occlusive disease in renal transplant recipients: risk factors and impact on kidney allograft survival

BACKGROUND

This study evaluated the relationship between renal transplantation and the evolution of lower extremity peripheral vascular occlusive disease (PVOD).

METHODS

A total of 664 adult renal allograft recipients from 1985-1995 were retrospectively reviewed for atherosclerotic risk factors and peripheral vascular occlusive disease (PVOD). PVOD events were defined as bypass, major amputation, claudication, or percutaneous angioplasty. Follow-up ranged from 2-12 years.

RESULTS

The cumulative 5- and 10-year incidences of lower extremity PVOD after renal transplantation were 4.2 and 5.9%. Eight of 14 patients (57%) with pretransplant PVOD had additional PVOD events versus de novo appearance of PVOD in 21/650 patients (3.2%; P<0.0001). In a proportional hazards model, age, preoperative PVOD, diabetes, and postoperative smoking were independent risk factors for the development of PVOD after transplantation. Recipients with lower extremity PVOD had significantly lower 10-year patient and graft survival. Increased graft failure was due to an excess of deaths with a functioning graft. A total of 34 major interventions were performed. One- and two-year limb salvage rates were 64.2 and 53.8%.

CONCLUSIONS

Lower extremity PVOD after renal transplantation is associated with diminished patient survival, and affects kidney graft survival via disproportionate patient attrition. Age, preoperative PVOD, diabetes, and postoperative smoking are important risk factors. Transplantation does not appear to either accelerate or retard the progression of disease. An aggressive approach towards limb salvage in properly selected patients is justifiable.

The safety of combined cardiac and vascular operations: how much is too much?

OBJECTIVE

The purpose of this study was to identify factors correlating with a poor outcome following combined cardiac and vascular procedures.

METHODS

We reviewed 45 consecutive patients undergoing combined cardiac and vascular operations. These included cardiac/CEA (n=27), cardiac/AAA (n=13), cardiac/AAA/one other vascular reconstruction (n=4), and cardiac/renal artery bypass (n=1). Group I included all patients with no morbidity or mortality (n=41) and Group II included patients who died or suffered significant morbidity (stroke, renal failure) (n=4).

RESULTS

Overall mortality was 4.4% (2/45). These two patients underwent cardiac surgery combined with two additional vascular procedures (cardiac/AAA/other). In patients undergoing cardiac/CEA or cardiac/AAA, there were no deaths and one stroke (contralateral to CEA). Group II had significantly decreased ejection fraction (39%+/-6% vs 52%+/-1%) and an increased number of procedures (2.75 vs 2.04).

CONCLUSIONS

Combined cardiac surgery and vascular reconstruction can be performed safely. However, multiple vascular reconstructions or the presence of decreased ejection fraction increased operative risk.

The Influence of Anesthetic Technique on Perioperative Blood Pressure Control after Carotid Endarterectomy

The optimal anesthetic for use during carotid endarterectomy has been a matter of debate for three decades. The goal of this study is to evaluate the influence of anesthetic technique on perioperative hemodynamic instability after carotid endarterectomy. This study is a retrospective chart review and was performed in a community teaching hospital. All consecutive patients undergoing carotid endarterectomy over a 2-year period at Providence Hospital were reviewed. One hundred ninety-eight patients underwent 203 carotid endarterectomies. Two patients were excluded because of combined coronary artery bypass grafting. Patients underwent carotid endarterectomy and were divided into two groups on the basis of use of general or regional anesthesia. Blood pressure was recorded hourly for the subsequent 24 hours, and the doses of vasoactive medications received to maintain the blood pressure within 25 mm Hg of preoperative levels were recorded. Patients receiving general anesthesia were found to require significantly more sodium nitroprusside for control of hypertension compared with those receiving regional anesthesia (72.1 ± 14.5 μg/kg vs 20.2 ± 6.6 ug/kg; P = 0.001) in the first 8 postoperative hours. No significant differences were noted in the doses of any other vasoactive medications used. No differences were found in the subsequent 16-hour period in doses of vasoactive medications. Patients suffering myocardial infarctions were found to receive higher doses of nitroglycerine, but no differences were noted in any other vasoactive medication used based on complications. Length of stay was longer in the general anesthesia group compared with the regional anesthesia group for both the intensive care unit (1.59 ± 0.13 days vs 1.08 ± 0.03 days; P = 0.001) and total hospital stay (5.8 ± 0.03 days vs 4.5 ± 0.02 days; P = 0.003). Regional anesthesia required lower doses of antihypertensive medication in the early postoperative period when compared with general anesthesia. The doses of vasoactive medications used had no significant impact on the complication rate. Regional anesthesia allowed for shorter stay in both the intensive care unit and total hospital stay.

Exercise equilibrium radionuclide angiography predicts long-term cardiac prognosis in patients with abdominal aortic aneurysm being considered for surgery

BACKGROUND

Patients with an abdominal aortic aneurysm (AAA) have a high prevalence of coronary disease and are at risk for cardiac events. This may offset the prognostic benefit of surgical repair. We investigated whether preoperative exercise equilibrium radionuclide angiography (ERNA) could be used to identify patients at high risk for cardiac events after successful AAA repair.

METHODS

Between 1990 and 1995, 173 patients with an AAA were referred for supine bicycle exercise ERNA preoperatively. Follow-up information was obtained from a questionnaire sent to each patient's family physician. Cardiac events were defined as cardiac death or nonfatal myocardial infarction.

RESULTS

A total of 139 patients were able to exercise and did not die or suffer myocardial infarction perioperatively. The median follow-up period was 3.8 years. Diabetes mellitus, an exercise ejection fraction (EF) below 0.50, and a fall in EF with exercise were univariable predictors of cardiac risk during the follow-up period (P < .05). On multivariable analysis, diabetes mellitus (risk ratio [RR], 6.9; 95% CI 1.5 to 32.0) and an EF fall (RR, 4.1; 95% CI 1.5 to 11.4) emerged as the most important predictors.

CONCLUSIONS

Exercise ERNA predicts long-term cardiac events in patients being considered for elective AAA repair. Such predictive information may influence the decision to operate, for example, on small unthreatening aneurysms, or lead to invasive cardiological management to minimize risk.

Feasibility of using dynamic contrast-enhanced magnetic resonance angiography as the sole imaging modality prior to endovascular repair of abdominal aortic aneurysms

OBJECTIVES

to establish the feasibility of using magnetic resonance imaging (MRI) with dynamic contrast-enhanced (DCE) MRA as the sole imaging modality in the assessment of patients prior to endovascular repair of abdominal aortic aneurysms (AAAs).

DESIGN

DCE MRA with MRI and helical computed tomography (CT) examinations were performed in patients being assessed for suitability for an endovascular approach to repair of their AAA. Management outcomes determined by the two techniques were compared.

MATERIALS

sixteen patients with AAA.

METHODS

all subjects underwent DCE MRA/MRI and helical CTA. Criteria for suitability for endovascular repair were established. The management outcomes determined by the MRI findings were compared with those obtained by CTA.

RESULTS

high-quality MRA/MRI and CT images were obtained in 16 patients. Six patients were considered suitable for an endovascular approach, one was considered borderline and nine were judged unsuitable. In all cases, the overall management determined by the two methods concurred.

CONCLUSIONS

comparison of the two imaging modalities resulted in agreement as to suitability for an endovascular approach. We therefore conclude that in our group the use of MRI and DCE-MRA proved effective as a sole imaging modality for the assessment of these patients.

Negative impact of cardiac evaluation before vascular surgery

The optimal preoperative evaluation of cardiac risk in patients with peripheral vascular disease is controversial. In developing a paradigm for preoperative cardiac workup, potential adverse effects of evaluation and cardiac intervention must be considered. This study analyzed the deleterious outcomes of extensive, comprehensive cardiac evaluation and intervention before planned vascular surgery in patients treated at the Denver Department of Veterans Affairs Medical Center. Over a 12-month period between 1994 and 1995, 161 patients were scheduled to undergo major vascular operations; 153 patients came to operation. The decision to pursue a cardiac evaluation was variously made by a combination of surgeons, cardiologists, and anesthesiologists. No defined protocol was followed. Cardiac history, chest X-rays and ECGs were obtained for all patients. Extended cardiac evaluation included these studies plus special tests, including echocardiography (echo), radionuclide ventriculography (RNVG), dipyridamole thallium scintigraphy (DTS), and cardiac catheterization (CC). Extended cardiac evaluations were undertaken in 42 patients. Complications related to percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) were also recorded. Cardiac mortality and morbidity after vascular interventions were itemized in all 153 patients. Forty-two male patients, aged 68 +/- 9 years, underwent extended cardiac evaluations before planned vascular operations. The median elapsed time for cardiac workup was 14 days (mean 30 +/- 59 days). The median and mean times from cardiac workup to vascular surgery were 25 days and 76 +/- 142 days, respectively. Eighteen (43%) patients had echo or RNVG; 22 (52%) patients had DTS; 27 (64%) had CC; 9 (21%) had PTCA; 7 (17%) had CABG. Sixteen (38%) patients had untoward events related to cardiac evaluation. Eight patients (19%: one with cerebrovascular disease, and seven with aortic aneurysms) refused vascular surgery after extended cardiac workup. Complications attributable to CC, PTCA, and CABG included prosthetic graft infection, pseudoaneurysms (two), sternal wound infections (two), renal failure and brain anoxia. Two patients with severe limb ischemia who were candidates for revascularization ultimately required amputations because of delay due to cardiac evaluations. Extensive cardiac evaluation prior to vascular operations can result in morbidity, delays, and refusal to undergo vascular surgery. The underlying indication for vascular operations and the local iatrogenic cardiac complication rates must be considered before ordering special studies.