Surgical therapy for coronary artery disease among patients with combined coronary artery and peripheral vascular disease

Current management of coronary artery disease prior to vascular surgery: A clinical dilemma

Here we present a case of an elderly man who underwent cardiac stress testing as a preoperative evaluation prior to femoral-popliteal bypass surgery. He subsequently underwent a preoperative coronary angiogram after a high-risk stress test with the latter demonstrating obstructive three-vessel coronary artery disease. We discuss the clinical challenges that such a common clinical scenario presents particularly when it comes to preoperative coronary revascularisation prior to vascular surgery. We examine the case within the framework of the latest revascularisation guidelines and discuss the available evidence for preoperative revascularisation and its limitations.

Prevalence and Prognostic Significance of Polyvascular Disease in Patients Hospitalized With Acute Decompensated Heart Failure: The ARIC Study

BACKGROUND

Polyvascular disease is associated with increased mortality rates and decreased quality of life. Whether its prevalence or associated outcomes differ for patients hospitalized with heart failure with reduced vs preserved ejection fraction (HFrEF vs HFpEF, respectively) is uncertain.

METHODS

The Atherosclerosis Risk in Communities (ARIC) study conducted hospital surveillance of acute decompensated heart failure (ADHF) from 2005-2014. Polyvascular disease (coexisting disease in ≥ 2 arterial beds) was identified based on the finding of prevalent coronary artery disease, peripheral artery disease or cerebrovascular disease. Mortality risks associated with polyvascular disease were analyzed separately for HFpEF and HFrEF, with adjustment for potential confounders. All analyses were weighted by the inverse of the sampling probability.

RESULTS

Of 24,937 weighted (5460 unweighted) hospitalizations due to ADHF (52% female, 32% Black, mean age 75 years), polyvascular disease was prevalent in 22% with HFrEF and in 17% with HFpEF. One-year mortality risks increased sequentially with 0, 1 and ≥ 2 arterial bed involvement, both for patients with HFrEF (29%-32%-38%; P trend = 0.0006) and for those with HFpEF (26%-32%-37%; P trend < 0.0001). After adjustments, polyvascular disease was associated with a 26% higher mortality hazard for patients with HFrEF (HR = 1.26; 95% CI: 1.07-1.50) and a 29% higher hazard for patients with HFpEF (HR = 1.29; 95% CI: 1.03-1.62), with no interaction by HF type (P interaction = 0.9).

CONCLUSION

Patients hospitalized with ADHF and coexisting polyvascular disease have an increased risk of death, irrespective of HF type. Clinical attention should be directed toward polyvascular disease, with implementation of secondary prevention strategies to improve the prognosis of this high-risk population.

SUMMARY

Polyvascular disease is known to be associated with myocardial infarction, stroke or cardiovascular death and is a major risk factor for decreased quality of life. This study sought to evaluate the relationship between polyvascular disease and mortality in patients hospitalized with acute decompensated heart failure (ADHF), and to understand whether the associations differ based on ejection fraction. Patients hospitalized with ADHF and coexisting polyvascular disease had an increased risk of death, irrespective of heart failure type, implying the need for increased clinical attention directed toward polyvascular disease, along with implementation of secondary prevention strategies to improve prognosis.

TWEET

Patients hospitalized with acute HF and coexisting polyvascular disease face an increased risk of death, irrespective of HF type.

Routine preoperative doppler ultrasound examination of arterial system in patients undergoing cardiac surgery is beneficial: A retrospective study

Background:

Presence of peripheral vascular disease enhances surgical risk in cardiac surgical patients. Prior knowledge of peripheral arterial disease may help the physician make changes in the monitoring and cardiopulmonary bypass cannulation plans. It is claimed that the incidence of peripheral vascular disease in cardiac surgical patients ranges from 11 to 30%.

Aims:

This study was conducted to understand the characteristics of peripheral vascular disease and their implication on cardiac surgery.

Settings and Design:

This was a prospective study undertaken in a tertiary referral hospital.

Materials and Methods:

All adult patients who underwent cardiac surgery during the period of six months were included. A Doppler examination of the neck, upper limb, abdomen and lower limb was carried out by our inhouse radiologist. The incidence of peripheral vascular disease, the implication on invasive pressure monitoring site and cannulation for cardiopulmonary bypass or intraaortic balloon pump or extracorporeal membrane oxygenation were made note of.

Results:

During the said period, six hundred twenty eight patients underwent cardiac surgery, of whom five hundred and sixty-one patients who underwent CABG surgery. All these were subjected to Doppler examination. We observed peripheral arterial disease in 105 patients (20%). In general men suffered from PAD more often than women. Monitoring site of invasive arterial pressure, the choice of beating heart surgery, insertion of intraaortic balloon pump, femoral arterial route for cardiopulmonary bypass were some of the decision that were altered.

Conclusions:

Performing Doppler examination in cardiac surgical patients may yield important data that might prevent complications and support patient safety.

The use of both internal thoracic arteries for coronary revascularization increases the estimate of post-operative lower limb ischemia in patients with peripheral artery disease

BACKGROUND

Patients with a history of peripheral arterial disease (PAD) undergoing coronary artery bypass grafting (CABG) exhibit higher rates of complications. There are conflicting data on the survival benefits for bilateral thoracic artery (BITA) grafting compared with left internal thoracic artery (LITA) CABG in patients with PAD. The aim of the study was to explore the influence of the use of BITA grafts vs. LITA for CABG on post-operative acute lower limb ischemia (ALLI) and main post-operative complications in patients with concomitant PAD.

METHODS

We used a propensity-score (PS) based analysis to compare outcomes between the two surgical procedures, BITA and LITA. The inverse probability of treatment weighting PS technique was applied to adjust for pre- and intra-operative confounders, and to get optimal balancing of the pre-operative data. The primary outcome was the estimate of postoperative ALLI. Secondary outcomes included overall death and death of cardiac causes within 30 days of surgery, stroke and acute kidney disease (AKD).

RESULTS

The study population consisted of 1961 patients. The LITA procedure was performed in 1768 patients whereas 193 patients underwent a BITA technique. The estimate of ALLI was 14% higher in the BITA compared to the LITA (p < 0.001) group. Thirty-day mortality, cardiac death, occurrence of stroke and AKI did not differ significantly between the groups.

CONCLUSIONS

The use of both ITAs led to a significant increase in ALLI. This result was most likely caused by the complete disruption of the ITA collateral providing additional blood supply to the lower extremities. Based on our data, BITA should be used with extreme caution in PAD patients. Further research on this topic is necessary to confirm our findings.

Preoperative Cardiac Stress Testing in the Southern California Vascular Outcomes Improvement Collaborative

BACKGROUND

The objective of this study was to examine the use of preoperative cardiac stress testing (PCST) in the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe).

METHODS

A retrospective review was performed on data in all modules of the So Cal VOICe from September 2012 through May 2016. PCST was defined as stress echocardiogram or nuclear stress test. A new postoperative myocardial infarction (MI) was defined as troponin elevation and/or electrocardiogram/imaging changes with or without ischemic symptoms. Only elective cases in patients with asymptomatic cardiac status were included in the study.

RESULTS

During the study period, 3,063 procedures meeting the inclusion criteria were performed in 7 registries: carotid endarterectomy (CEA), carotid artery stent, thoracic endovascular aneurysm repair, infrainguinal bypass (Infra), endovascular aneurysm repair (EVAR), suprainguinal bypass (Supra), and open abdominal aortic aneurysm repair (OAAA). PCST varied across registries from 17% in PVI to 62% in OAAA. PCST in CEA varied across 9 institutions from 10% to 79%. PCST in EVAR varied across 7 institutions from 14% to 83%. PCST in Infra varied across 4 institutions from 10% to 57%. Of the 12 patients across all registries who had a new MI, 6 had PCST, one of which was abnormal.

CONCLUSIONS

The incidence of PCST varies widely across registries and institutions in the So Cal VOICe. Despite the wide variation, the incidence of new postoperative MI is exceptionally low. Further studies should evaluate the cost-effectiveness of the PCST practices and future quality improvement efforts should focus on standardization of indications for PCST.

Coronary risk in candidates for abdominal aortic aneurysm repair: a word of caution

BACKGROUND

Current guidelines do not recommend routine coronary evaluation preceding abdominal aortic aneurysms (AAA) repair in low-risk patients. The purpose of the present study is to report the incidence of coronary lesions in candidates for AAA repair with a Revised Cardiac Risk (Lee) Index (RCRI) < 2, which are usually excluded from preoperative cardiological work-up. Early-term and long-term results of prophylactic myocardial revascularization are also reported.

METHODS

A retrospective, observational, cohort study collecting clinical data on a series of 149 consecutive patients undergoing preoperative coronary angiography and myocardial revascularization (percutaneous coronary intervention, PCI; coronary artery bypass grafting, CABG) before elective open or endovascular AAA repair (January 2005-December 2012).

RESULTS

Severe coronary artery disease (CAD) was revealed in 43 patients (28.9%), who underwent successful myocardial revascularization by means of PCI (n.35) or off-pump CABG (n.8). The incidence of severe CAD in patients resulted at low risk on the basis of risk models was approximately 25%. The incidence of severe CAD in asymptomatic patients was 29.8%. Endovascular (n.52, 35.1%) and open (n.96, 64.9%) AAA repair was performed with low morbidity (0.6%) and mortality (0.6%) in 148 patients. The long-term estimated survival (freedom from fatal cardiovascular events) was 97% at 60 months and 82% at 90 months.

CONCLUSIONS

The incidence of severe correctable CAD is not negligible in low-risk patients scheduled for AAA repair. Waiting for further recommendations based on large population studies of vascular patients, a more extensive indication to coronary angiography and revascularization should be considered in many candidates for AAA repair.

Does the presence of coronary artery disease impact perioperative outcomes following partial hepatectomy?

INTRODUCTION

Coronary artery disease (CAD) is often considered a contraindication to hepatectomy despite a lack of data to support this practice. The purpose of this study is to evaluate the impact of CAD on postoperative outcomes in patients undergoing hepatectomy.

MATERIAL AND METHODS

A total of 1,206 consecutive patients undergoing hepatectomy from August 1995 to June 2009 were included. Propensity matching was performed to identify differences in morbidity and mortality between patients with and without CAD. Subgroup analyses were performed to stratify patients based on the severity of CAD and the interval between coronary intervention and hepatectomy.

RESULTS

Of all patients, 138 (11.4%) had a diagnosis of CAD and were more likely to have a malignant diagnosis and other comorbid conditions including renal insufficiency, COPD, and diabetes. Matched patients with CAD had no significant differences in complication rates, with 2.2 and 5.8% of CAD patients experiencing a postoperative myocardial infarction or arrhythmia, respectively. Propensity matching failed to identify differences in mortality or morbidity. Subgroup analysis revealed similar rates of mortality and complications regardless of the severity of CAD or the time interval between coronary intervention and hepatectomy.

CONCLUSION

Despite the increased prevalence of major medical comorbidities, selected patients with CAD can safely undergo hepatectomy with acceptable rates of postoperative morbidity and mortality.

Amputation and cardiac comorbidity: analysis of severity of cardiac risk

OBJECTIVE

To evaluate population-based cardiovascular risk scores and coronary artery calcification scores (CACS) in amputees.

DESIGN

A retrospective cohort study of 1300 veterans in a cardiac computed tomography database.

SETTING

1B Veterans Administration medical center.

PARTICIPANTS

A total of 76 amputees and similar number of age-, gender-, and Framingham Risk Scores (FRS)-matched control subjects.

METHODS

The amputee population was identified and compared for CACS and traditional cardiac risk factors. Two control groups were used: control group 1, with known risk factors including diabetes mellitus, and control group 2, with all risk factors without diabetes mellitus.

MAIN OUTCOME MEASURES

Statistical associations between amputee and control group FRS scores, CACS, and other cardiac risk factors were assessed.

RESULTS

The study included 57 nontraumatic and 19 traumatic amputees with an average age of 62.4 years. Sixty-six amputees were in the low-to-intermediate cardiac risk groups according to FRS. Despite this classification, the mean CACS were significantly higher in amputees (1285 ± 18) than in either of the control groups: control group 1 (540 ± 84) and control group 2 (481 ± 11), P < .001. CACS also were significantly higher in the nontraumatic subject group (1595 ± 12) compared with the traumatic group (356 ± 57; P < .001). Upon categorization of CACS based on probability of coronary artery disease (CAD), 76% of amputees had a CACS >100 and 38% of amputees had a CACS >1000. Interestingly, CACS were almost the same in finger/toe amputations compared with an above-knee amputation, indicating an already ongoing CAD process irrespective of level of amputation. The predominant clinical significant cardiac risk factors in amputees are hypertension (89.5%), P < .005; chronic kidney disease (31.6%), P < .001; dyslipidemia (72.4%), P < .04; and insulin resistance. Total cholesterol, low-density lipoprotein, and high-density lipoprotein levels were nonsignificantly low in all amputees. Triglycerides were particularly higher in traumatic patients compared with nontraumatic patients, with the triglycerides/high-density lipoprotein ratio >7.

CONCLUSION

This study demonstrates that amputees have a much greater burden of underlying atherosclerotic disease as detected by CACS than do control subjects matched by Framingham risk stratification. Early screening for CAD and aggressive targeted interventions may be an important part of management to reduce early mortality after amputation.

Preoperative stress testing in high-risk vascular surgery and its association with gender

BACKGROUND

Despite significant improvement in anesthetic and surgical techniques, the incidence of perioperative myocardial infarction (PMI) and all-cause mortality from any cardiac event during high-risk vascular surgery (abdominal aortic or infrainguinal revascularization procedures) remains high. In addition, there are significant health care costs associated with the management of PMI.

OBJECTIVES

The aim of this analysis was to investigate the utility of routine preoperative myocardial stress testing prior to high-risk vascular surgery and the interventions performed based on the results of the testing. The outcome after surgery, based on sex of the patients, was also examined.

METHODS

A retrospective analysis was performed on consecutive adult patients who had a positive dipyridamole-thallium stress test prior to high-risk vascular surgery in a university hospital (tertiary care center) between July 2001 and August 2004. The patients' preoperative demographic characteristics, perioperative record, and postoperative course in the hospital were analyzed. Combined major adverse outcome was defined as any incidence of MI, congestive heart failure, arrhythmias, renal failure, or death.

RESULTS

Of a total of 503 patients, 160 had a positive stress test prior to high-risk vascular surgery (111 men, 49 women; mean [SD] age, 68 [11] and 70 [12] years, respectively). Men with a positive stress test who had either coronary intervention or perioperative β-blockade prior to surgery had a significant decrease in the incidence of combined major adverse outcomes (P = 0.02). Conversely, women did not have a significant improvement in outcome with either of the preoperative strategies. Using logistic regression, only age and conservative management in men were found to be predictors of adverse outcomes.

CONCLUSIONS

In this small retrospective study, men with positive stress tests had fewer adverse events with either preoperative coronary revascularization or perioperative administration of β-adrenergic blocking drugs, compared with men who received no intervention. There were no significant differences in adverse outcomes between women with positive stress tests who received either treatment compared with those who did not receive any treatment.

Coronary artery revascularization before peripheral vascular surgery in patients with peripheral arterial disease

The prevalence of coronary artery disease (CAD) in patients with peripheral arterial disease (PAD) approaches 50%. The incidence of perioperative cardiac complications is high in patients undergoing peripheral vascular surgery (PVS). However, the long-term efficacy of coronary artery revascularization in patients with PAD prior to PVS remains controversial. We retrospectively analyzed the long-term outcomes of 114 patients who underwent elective PVS. Coronary angiography (CAG) was performed routinely in all patients prior to the surgery. Preoperative CAG revealed CAD in 52 patients and no CAD in 62 patients (No-CAD group). Of the 52 patients with CAD, 15 patients with effort angina (more than CCS class 2), myocardial ischemia proven by pharmacological stress scintigraphy, and/or multivessel disease with impaired left ventricular systolic function underwent coronary revascularization (CAD-R group). The remaining 37 patients with CAD were treated medically (CAD-M group). The rates of postoperative events within 30 days were 26.7% in the CAD-R group, 10.8% in the CAD-M group, and 8.1% in the No-CAD group, respectively (P = 0.13), and the rates of long-term cardiovascular events were 33.3, 21.6, and 21.0%, respectively (P = 0.60). Therefore, the acute and long-term clinical outcomes in the CAD-R group were comparable with the other groups. In this study, the patients with CAD who showed inducible myocardial ischemia and/or multivessel disease with impaired left ventricular systolic function underwent coronary artery revascularization prior to the elective PVS. The patients who underwent coronary revascularization prior to the PVS exhibited comparable long-term outcomes compared with the patients who showed CAD but without inducible myocardial ischemia and with those without CAD. These data suggest that the evaluation of CAD and myocardial ischemia to determine the therapeutic strategy for CAD before elective PVS would be needed.

Concomitant peripheral artery disease and asymptomatic coronary artery disease: a management strategy

The present study examines the use of routine coronary angiography (CAG) before elective peripheral artery disease (PAD) surgery and the early outcome and technical features of simultaneous coronary revascularization and PAD surgery in PAD patients with asymptomatic coronary artery disease (CAD). We performed preoperative CAG in 82 patients who were undergoing elective peripheral arterial bypass surgery and who had no diagnosis or symptoms of ischemic heart disease. The 82 patients were grouped according to the criteria of <70% stenosis, >70% stenosis, and no coronary stenosis. In patients with >70% coronary artery stenosis, we performed simultaneous peripheral artery bypass surgery and coronary artery bypass grafting (CABG), while the other patients underwent peripheral artery bypass only. Preoperative coronary angiography revealed CAD in 69.5% (n = 57) of patients. Patients with CAD were more likely to be older, hypertensive, and diabetic than patients without CAD (all p < 0.05). Preoperative electrocardiography showed that only 3/57 (5.3%) patients with CAD had ischemic heart disease. Of the 61 patients who underwent peripheral artery bypass, 27 (47.4%) underwent simultaneous CABG. Of the patients with CAD, 78.9% (45/57) required peripheral artery bypass, whereas 64.0% (16/25) of patients without CAD required peripheral artery bypass (p = 0.11). Comparing simultaneous CABG and peripheral artery bypass in PAD patients with CAD and isolated peripheral artery bypass in PAD patients regardless of CAD, the only significant difference was in operating time (362.00 +/- 79.18 vs. 246.55 +/- 79.15 min, p = 0.00). When compared with PAD patients with CAD who underwent isolated peripheral artery bypass, the results were similar. Two patients who had CAD and underwent isolated peripheral artery bypass died (p = 0.16). Patients with peripheral arterial obstructive disease should be examined for CAD using CAG, regardless of whether they have symptomatic ischemic heart disease, and simultaneous CABG and peripheral artery bypass is safe and feasible.

Lower extremity peripheral arterial disease in individuals with coronary artery disease: prognostic importance, care gaps, and impact of therapy

BACKGROUND

Our objective was to examine the effect of concomitant lower extremity peripheral arterial disease (PAD) on long-term prognosis and pharmacotherapy in patients with coronary artery disease (CAD).

METHODS

Prospective cohort study enrolling all patients with angiographically proven CAD between April 1, 2000, and December 31, 2004, in Alberta, Canada.

RESULTS

Of 28,649 patients (mean age 64 years) with CAD, 2509 (9%) had a physician-assigned diagnosis of lower extremity PAD. Mortality was higher in the patients with CAD and PAD over a mean follow-up of 3.1 years, even after adjusting for the fact that patients with PAD had more severe CAD and more comorbidities (adjusted hazard ratio [HR] 1.41, 95% CI 1.28-1.55). Fewer patients with CAD and PAD received antiplatelet agents (83% vs 86%, odds ratio 0.86, 95% CI 0.77-0.97) or beta-blockers (63% vs 67%, odds ratio 0.89, 95% CI 0.82-0.98), but users of these agents exhibited lower mortality (adjusted HR 0.68, 95% CI 0.60-0.77, for antiplatelet agents and adjusted HR 0.72, 95% CI 0.64-0.80, for beta-blockers). Approximately half of these patients were prescribed statins or angiotensin-converting enzyme inhibitors, and 27% were using all 3 evidence-based anti-atherosclerotic therapies (antiplatelets, statin, and angiotensin-converting enzyme inhibitor).

CONCLUSIONS

In patients with CAD, lower extremity PAD is independently associated with poorer outcomes. Although all evidence-based therapies are underused in patients with CAD, patients with concomitant PAD are less likely to be prescribed antiplatelet agents or beta-blockers--both agents are associated with improved survival in patients with CAD and PAD.

Clinical factors associated with long-term mortality following vascular surgery: outcomes from the Coronary Artery Revascularization Prophylaxis (CARP) Trial

BACKGROUND

Preoperative cardiac risks and clinical indications for vascular surgery are both important determinants of outcome following a vascular operation. Using the nonrandomized cohort from the Coronary Artery Revascularization Prophylaxis (CARP) Trial, we analyzed the predictors of outcome based on the presenting vascular problem and prevalence of comorbid conditions and cardiac risks.

METHODS AND RESULTS

Between March 1, 1999 and February 28, 2003, 4414 patients were ineligible for randomization in the CARP Trial and their survival was retrieved through the BIRLS system (the Department of Veterans Affairs Beneficiary Identification and Records Locator Subsystem). Surgical indications were either an abdominal aortic aneurysm (N = 1598) or lower extremity ischemia for claudication (N = 1116), rest pain (N = 670), or tissue loss (N = 1030). Patients were screened for major cardiac risks that included a history of angina, congestive heart failure, myocardial infarction, ventricular arrhythmias, pathological q-waves, and diabetes. The absence of multiple cardiac risks, as the sole reason for exclusion from randomization, occurred in 2314 (52.4%) screened patients and their probability of survival at 2.5-year post-surgery was 0.88. This was better than the survival of the remaining excluded patients (N = 2100), which was 0.75 (P < .0001) and the randomized cohort (N = 462), which was 0.80 (P < .0001). By Cox regression analysis, urgent surgery, congestive heart failure, ventricular arrhythmias and creatinine >3.5 mg/dL were significantly associated with long-term postoperative mortality.

CONCLUSIONS

Patients without multiple cardiac risks or comorbid conditions have a good outcome following elective vascular surgery. Urgent surgery, creatinine >3.5 mg/dL, congestive heart failure, and ventricular arrhythmias are identifiers of a poor long-term outcome and may justify aggressive strategies for risk-stratification in the postoperative period.

The effects of prophylactic coronary revascularization or medical management on patient outcomes after noncardiac surgery - a meta-analysis

PURPOSE

The benefits of prophylactic coronary revascularization for patients undergoing noncardiac surgery are uncertain. The purpose of this study was to systematically evaluate the effect of coronary revascularization and medical management on short- and long-term outcomes after noncardiac surgery.

METHOD

Ten electronic databases including MEDLINE and EMBASE (1980 to February 2006), and bibliographies of included articles were searched without language restrictions. Studies comparing effects of coronary revascularization and medical management before noncardiac surgery were included. Patient outcome data including perioperative mortality, myocardial infarction, long-term mortality, or late adverse cardiac events were extracted and entered into a meta-analysis.

RESULTS

The quality of published evidence was modest, comprising one randomized controlled trial and six retrospective studies. A total of 3,949 patients undergoing high-risk noncardiac surgery were included in the quantitative analysis. There was no significant difference between coronary revascularization and medical management groups with regards to postoperative mortality and myocardial infarction; the odds ratios (95% confidence intervals) were 0.85 (0.48-1.50) and 0.95 (0.44-2.08), respectively. There were no long-term outcome benefits associated with prophylactic coronary revascularization; the odds ratios (95% confidence intervals) were 0.81 (0.40-1.63) and 1.65 (0.70-3.86) for long-term mortality and late adverse cardiac events, respectively.

CONCLUSION

In patients with stable coronary artery disease, prophylactic coronary revascularization before high-risk noncardiac surgery does not confer any beneficial effects, when compared with optimized medical management, in terms of perioperative mortality, myocardial infarction, long-term mortality, or adverse cardiac events.

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.

Coronary-artery revascularization before elective major vascular surgery. McFalls EO, ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG. N Engl J Med. 2004; 351: 2795-804

Question: In patients with clinically stable coronary artery disease, who are scheduled for elective abdominal aortic or infrainguinal vascular surgery, does prophylactic coronary artery revascularization prior to vascular surgery reduce long-term mortality?

Population: Patients met inclusion criteria if they were undergoing elective vascular surgery and a cardiologist considered them at increased risk for perioperative cardiac complications based on clinical risk factors or the presence of ischemia on nuclear stress imaging. After coronary angiography, patients were considered eligible for randomization if they had a <70% stenosis in one or more major coronary artery that was suitable for revascularization. Patients with unstable angina, stenosis of the left main coronary artery of >50%, left ventricular ejection fraction <20%, or severe aortic stenosis were excluded from the trial.

Design and methods: During 1997-2003 from 18 Veterans Administration centers in the USA, 5859 patients were screened, of which 80% were initially excluded because of insufficient cardiac risk or no evidence of ischemia on nuclear imaging ( n = 2280), urgent vascular surgery ( n = 1025), severe coexisting comorbidities ( n = 731), or refusal to participate or enrolment in other studies ( n = 633). Of the remaining 1190 patients who underwent coronary angiography, 680 (57%) were excluded for the following reasons: non-occlusive or non-operable coronary artery disease 363 (53%) and 215 (32%), respectively; and exclusions (e.g. left main coronary artery disease) 15%. A randomized design was used to assign 510 patients (98% men) to a strategy of preoperative coronary artery revascularization ( n = 258), or no revascularization ( n = 252), before vascular surgery. Of the participants, 74% had more than three of the Eagle clinical criteria, or more than two of the variables of the Revised Cardiac Risk Index, or a moderate to large reversible defect on imaging (71% of the 65% participants who received nuclear stress tests). Also, 33% of participants had three-vessel coronary artery disease. The choice of coronary revascularization, either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), was left to the discretion of the study centers. The primary outcome was long-term all-cause mortality. Secondary outcomes were perioperative mortality or myocardial infarction, stroke, limb loss, or dialysis. The analysis followed the intention-to-treat principle.

Results: Median follow-up was 2.7 years and follow-up was 100% complete. Long-term all-cause mortality did not differ between the two groups: 67 (26%) patients in the non-revascularization group and 70 (27%) patients in the revascularization group died (RRR 4%; 95% CI - 32 to 30). There was also no difference in perioperative mortality ( p = 0.87), myocardial infarction ( p = 0.37), stroke ( p = 0.59), limb loss ( p = 0.11), and dialysis ( p = 0.97).

Conclusions: In patients with clinically stable coronary artery disease, who are scheduled for elective abdominal aortic or infrainguinal vascular surgery, prophylactic coronary artery revascularization using PCI or CABG prior to surgery did not reduce long-term all-cause mortality.

Correlation of preoperative ankle-brachial index and pulse volume recording with impaired saphenous vein incisional wound healing post coronary artery bypass surgery

Patients undergoing coronary artery bypass surgery have vascular disease and, subsequently, the risk for impaired healing of their saphenous vein graft site. The purpose of this study was to identify the correlation of the preoperative ankle-brachial index (ABI) and pulse volume recording (PVR) with impaired saphenous vein incisional wound healing post coronary artery bypass grafting. A prospective, correlational research design was used to study 271 male and female adults undergoing coronary artery bypass surgery in which the saphenous vein was used for grafting. Arterial insufficiency was assessed preoperatively using patient history, physical examination, ABI, and PVR. Wound status was assessed postoperatively using the validated ASEPSIS tool for inpatients. A modified ASEPSIS tool, the Wound Healing Self Score, was used for telephone follow-up post discharge. Abnormal ABI and PVR measurements were positively correlated with impaired saphenous vein incisional wound healing (r = 0.72, P < .0001). Both tests also independently predicted impaired healing. Incisional infection correlated with impaired healing (P < .0001). Other clinical variables, including diabetes, hypertension, venous disease, and alcohol and cigarette use, were not found to be statistically significant independent predictors of impaired healing. Routine histories and physical examinations alone are insufficient in predicting risk for impaired saphenous vein incisional wound healing. The addition of noninvasive screening for the presence of arterial insufficiency before coronary artery bypass grafting using ABI and PVR tests is one method of predicting the likelihood of impaired healing.

Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation

AIMS

The objectives of this study are to evaluate the prognostic role of pre-operative stratification in patients undergoing elective major vascular surgery, the timing of adverse outcomes, and the predictive role of troponin (cTn).

METHODS AND RESULTS

Consecutive vascular surgery candidates (n=391) were prospectively stratified and treated according to the ACC/AHA guidelines. The patients were categorized into three groups: (1) with coronary revascularization in the past 5 years, (2) with intermediate clinical risk predictors, and (3) with minor or no clinical risk predictors. cTnI was measured post-operatively. By 18 months, 18.7% of subjects had experienced death or acute myocardial infarction (MI) (by the ACC/ESC criteria). The hazard ratio (HR) was 5.21 (95% CI=2.60-10.43; P<0.0001) in group 1 and 2.58 (95% CI=1.27-4.38; P=0.004) in group 2 when compared with group 3. Most events occurred within 30 days. Elevations of cTnI were associated with adverse outcomes even after multivariable adjustment at long-term (adjusted overall HR=4.73, 95% CI=2.92-7.65; P<0.0001) and at 30 days (adjusted HR=5.52, 95% CI=3.23-9.42; P<0.0001).

CONCLUSION

After pre-operative stratification, patients undergoing elective major vascular surgery remain at high risk of MI and death. Events occur mainly early after surgery. cTnI elevations are frequent and independently associated with increased risk. These findings suggest the need for a major re-evaluation of our approach to these patients.

Coronary-artery revascularization before elective major vascular surgery

BACKGROUND

The benefit of coronary-artery revascularization before elective major vascular surgery is unclear.

METHODS

We randomly assigned patients at increased risk for perioperative cardiac complications and clinically significant coronary artery disease to undergo either revascularization or no revascularization before elective major vascular surgery. The primary end point was long-term mortality.

RESULTS

Of 5859 patients scheduled for vascular operations at 18 Veterans Affairs medical centers, 510 (9 percent) were eligible for the study and were randomly assigned to either coronary-artery revascularization before surgery or no revascularization before surgery. The indications for a vascular operation were an expanding abdominal aortic aneurysm (33 percent) or arterial occlusive disease of the legs (67 percent). Among the patients assigned to preoperative coronary-artery revascularization, percutaneous coronary intervention was performed in 59 percent, and bypass surgery was performed in 41 percent. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the group not undergoing revascularization (P<0.001). At 2.7 years after randomization, mortality in the revascularization group was 22 percent and in the no-revascularization group 23 percent (relative risk, 0.98; 95 percent confidence interval, 0.70 to 1.37; P=0.92). Within 30 days after the vascular operation, a postoperative myocardial infarction, defined by elevated troponin levels, occurred in 12 percent of the revascularization group and 14 percent of the no-revascularization group (P=0.37).

CONCLUSIONS

Coronary-artery revascularization before elective vascular surgery does not significantly alter the long-term outcome. On the basis of these data, a strategy of coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended.

Strategies in the high-risk cardiac patient undergoing non-cardiac surgery

The risk of perioperative myocardial infarction or cardiac death in patients undergoing non-cardiac surgery may be estimated by clinical risk factor analysis and by myocardial stress testing. While stress testing modalities accurately delineate reversible myocardial ischaemia, their positive predictive value is low, and it is not clear whether their implementation improves outcome when compared to risk stratification alone. Similarly, it remains to be shown that preoperative coronary revascularization is an effective strategy in reducing perioperative risk. Recent reports indicate that surgery undertaken in the first weeks after percutaneous coronary interventions may be associated with a significantly increased rate of major complications. Administration of beta-blockers and alpha2-adrenergic agonists to high-risk patients reduces surgical morbidity and mortality, and the benefits observed with beta-blockers may extend long after the operative period. In high-risk patients undergoing major surgery, pulmonary artery catheter-guided haemodynamic optimization has not been associated with better outcomes, whereas use of regional anesthetic techniques decreases the incidence of postoperative pulmonary, but not cardiac, complications.

Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass

BACKGROUND

An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients.

METHODS

Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8.

RESULTS

Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001).

CONCLUSIONS

Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.

Impact of extracardiac vascular disease on acute prognosis in patients who undergo percutaneous coronary interventions (data from the Blue Cross & Blue Shield of Michigan Cardiovascular Consortium [BMC2])

Extracardiac vascular disease is associated with an increased risk of in-hospital mortality and other complications after coronary interventions, independent from other co-morbidities and baseline characteristics. The underlying cause of this significant association is unclear, but it warrants further investigation in an attempt to improve outcome in this high-risk cohort.

An appraisal of different cardiac risk reduction strategies in vascular surgery patients

OBJECTIVES

to summarize existing evidence regarding the benefits and the risks of all available interventional and medical means aimed at cardiac risk reduction in patients undergoing vascular surgery.

DESIGN

review of the literature.

MATERIALS AND METHODS

a critical review of all studies examining the impact of various prophylactic cardiac maneuvers on perioperative outcome following vascular surgery was performed. Overall mortality, cardiac mortality and myocardial infarction rate were used as the outcome measures.

RESULTS

coronary artery bypass grafting is associated with a 60% decrease in perioperative mortality in patients undergoing vascular surgery, but in most of the cases this decrease does not outweigh the combined risk of the cardiac and the subsequent noncardiac vascular procedure. Data supporting the cardioprotective effect of percutaneous transluminal angioplasty in the perioperative setting are insufficient. beta-blockade has been shown to decrease perioperative mortality and cardiac morbidity in both high-risk (strong evidence) and low-risk (weak evidence) patients.

CONCLUSIONS

coronary revascularization is rarely indicated to simply get the patient through vascular surgery and should be reserved for patients who would need it irrespective of the scheduled vascular procedure. Among all available pharmacological agents, including beta-blockers, alpha-agonists, calcium channel blockers and nitrates, only beta-blockers have been proven to reduce the cardiac risk of vascular surgery.

Peripheral vascular disease as predictor of outcome after coronary artery bypass grafting

BACKGROUND AND AIMS

Understanding and objective assessment of risks is crucial in cardiac surgery. The aim of this study was to assess the influence of peripheral vascular disease (PVD) on morbidity, mortality and outcome in coronary artery bypass grafting (CABG) patients.

MATERIAL AND METHODS

The ankle-brachial pressure index (ABPI) was used as indicator of PVD and was measured in 178 CABG patients. Two groups were established: 1. normal ABPI (0.9-1.3) (n = 136) and 2. lowered ABPI (< 0.9) (n = 35). The mean follow-up was 26 months.

RESULTS

The presence of PVD was 20.5 %. Patients with PVD were older (p < 0.05), more often of female sex (p < 0.05), had higher Higgins's risk score (p = 0.001) and more often intermittent claudication (IC) (p < 0.001). PVD significantly predicted atrial fibrillation (FA) (p < 0.05) and relatively postoperative myocardial infarction (MI) (p = 0.058).

CONCLUSIONS

The presence of PVD is relatively high in CABG patients and increases with age. PVD predicts some morbidity but seems to have fairly little influence on short-term or middle-term outcome of CABG patients. ABPI may be of only limited value in identifying patients with high operative risk in CABG.

Risk factors associated with acute lower extremity ischemia after coronary revascularization

Acute lower extremity ischemia (ALEI) is a recognized complication of coronary revascularization that can lead to emergent lower extremity revascularization, amputation, and death. Patients with correctable coronary artery disease have a high incidence of lower extremity arterial occlusive disease (AOD). But, despite the known high correlation between AOD and coronary artery disease, the status of the lower extremity vasculature in patients undergoing coronary revascularization may be overlooked until the lower extremity becomes profoundly ischemic. Data from a retrospective review of 35,000 coronary revascularization procedures identified 55 patients who developed ALEI, subsequent to their cardiac procedures. Risk factors for ALEI included femoral artery instrumentation, previous coronary revascularization, hemodynamic instability, and documented AOD. Means of identifying patients at risk for ALEI are discussed.

Cardiac risk assessment for noncardiac surgery: current concepts

Strategies for perioperative risk assessment in patients undergoing noncardiac surgery vary among physicians and are aimed to estimate the risk and minimize complications. We propose simplistic guidelines for assessing and modifying risk for patients undergoing a wide variety of procedures.

Cardiac Investigation and Intervention Prior to Thoraco-abdominal Aneurysm Repair: Coronary Angiography in 35 Patients

OBJECTIVE

retrospective studies indicate a high risk of cardiac events in patients undergoing thoraco-abdominal aneurysm repair. We aimed to determine the prevalence of coronary disease in these patients, define the role of non-invasive cardiac testing and assess the short-term outcome of coronary re-vascularisation.

DESIGN

a prospective cohort study of consecutive patients referred to a single surgeon.

MATERIALS AND METHODS

forty patients recruited over 16 months (Type I, 6; II, 11; III, 8; IV, 15). Dobutamine stress echocardiography, coronary angiography and coronary re-vascularisation (PTCA or CABG) were performed according to a pragmatic protocol. Main outcome measures were the prevalence of coronary artery disease, sensitivity and specificity of clinical assessment and non-invasive cardiac testing, and adverse events associated with coronary investigation and intervention.

RESULTS

seven patients (17.5%) were stratified as having high perioperative cardiac risk. The majority of patients (23, 57.5%) had no cardiac risk factor other than the operation type. Five patients (12.5%) had inducible ischaemia on non-invasive testing. Fourteen patients (40%) had haemodynamically significant coronary artery stenoses, of whom 12 (34%) underwent coronary revascularisation. Dobutamine stress echocardiography demonstrated 100% specificity and 71% sensitivity for the detection of significant coronary artery lesions. Coronary re-vascularisation by three-vessel bypass grafting was complicated by non-fatal stroke in one patient. Thirty-five patients (87.5%) proceeded to aneurysm repair. No patient who had been adequately investigated suffered a cardiac complication.

CONCLUSIONS

the 40% prevalence of coronary artery disease in these patients is comparable to that of other patients undergoing arterial surgery. Non-invasive testing proved beneficial, both in screening low-risk patients and planning intervention in patients at higher risk. An aggressive approach to intervention was associated with an acceptable complication rate and favourable short-term outcome.

Influence of peripheral vascular occlusive disease on the morbidity and mortality of coronary artery bypass grafting

The impact of peripheral vascular occlusive disease (PVD) on outcome for patients who have undergone coronary artery bypass grafting (CABG) was assessed by comparing preoperative and intraoperative patient characteristics and outcome in 2 groups of patients who underwent CABG (patients with PVD, n=96; patients without PVD, n=593). Patients with PVD were significantly older (69+/-8.4 vs 63+/-8.7; p<0.0001), and had a higher incidence of diabetes mellitus (48% vs 32%; p<0.01), hypertension (62% vs 46%; p<0.01), preoperative cerebral infarction (26% vs 12%; p<0.001) and chronic renal dysfunction (11% vs 4.4%; p<0.01) than those without PVD. Postoperative morbidity and mortality were assessed, after those risk factors were adjusted, using multivariate logistic regression analysis. The perioperative myocardial infarction (PMI) rate and in-hospital mortality rate were significantly higher in patients with PVD than in patients without PVD (9.4% vs 3.0%; p=0.0108, 17% vs 2.7%; p=0.0003, respectively). The odds ratio of PMI and in-hospital mortality were 3.4 (95% confidence intervals (CI): 1.3-8.6) and 4.3 (95% CI: 2.0-9.5), respectively. Although the excess mortality rate was mainly the result of cardiac problems, such as low output syndrome or arrhythmia, in most of the cases, PVD, which may frequently prevent the use of the intraaortic balloon pump, also seemed to have a strong relation to postoperative morbidity and mortality.

[Risk factors for mortality in abdominal aortic surgery]

OBJECTIVE

To analyse pre and peroperative variables for predicting mortality after abdominal aortic surgery.

STUDY DESIGN

Prospective study.

PATIENTS

We prospectively included 658 consecutive patients undergoing abdominal aortic surgery from January 1993 to July 1997.

METHODS

Age, gender, hypertension, history of myocardial infarction or coronary revascularization, angina pectoris, diabetes, arrhythmia, cardiac insufficiency, serum creatinine > 150 mumol.L-1, beta-blockers therapy, calcium channel inhibitors, angiotensin converting enzyme inhibitors were preoperative analysed variable. Type of aortic disease (anuerysms versus aortic occlusion), duration of surgery, blood loss, type of laparotomy (medium versus lombotomy) were peroperative analysed variables. Haemoglobinemia was monitored during surgery and patients were transfused if haemoglobinaemia < 80 g.L-1.

RESULTS

Thirty-three patients died after aortic surgery (5%). In multivariate analysis, angina pectoris (OR = 5.47, P < 0.001), chronic obstructive bronchopulmonary disease (OR = 2.27, P = 0.05) and duration of surgery (OR = 1.60, P < 0.001) were the independent predictive factors of mortality. Age, blood loss were predictive factors only in univariate analysis.

CONCLUSION

Angina pectoris and COBP were the two independent preoperative factors of mortality. The duration of surgery was the only peroperative factor. Well monitored blood loss was not a predictive factor.

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.