Dipyridamole-thallium/sestamibi before vascular surgery: a prospective blinded study in moderate-risk patients

PURPOSE: This study assessed in a prospective, blinded fashion whether a reversible defect on dipyridamole-thallium (DTHAL)/sestamibi (DMIBI) can predict adverse cardiac events after elective vascular surgery in patients with one or more clinical risk factors. METHODS: Consecutive patients with one or more clinical risk factors underwent a preoperative blinded DTHAL/DMIBI. Patients with recent congestive heart failure (CHF) or myocardial infarction (MI) or severe or unstable angina were excluded. RESULTS: Eighty patients (78% men; mean age, 65 years) completed the study. Diabetes mellitus was the most frequent clinical risk factor (73%), followed by age older than 70 years (41%), angina (29%), Q wave on electrocardiogram (26%), history of CHF (7%), and ventricular ectopy (3%). The results of DTHAL/DMIBI were normal in 36 patients (45%); a reversible plus or minus fixed defect was demonstrated in 28 patients (36%), and a fixed defect alone was demonstrated in 15 patients (19%). Nine adverse cardiac events (11%) occurred, including three cases of CHF, and one case each of unstable angina, Q wave MI, non-Q wave MI, and cardiac arrest (successfully resuscitated). Two cardiac deaths occurred (2% overall mortality), one after a Q wave MI and one after CHF and a non-Q wave MI. The cardiac event rate was 14% for reversible defect and 9.8% without reversible defect (P =.71). The cardiac event rate was 12.5% (one of eight cases) for two or more reversible defects, versus 11.1% (eight of 72 cases) for fewer than two reversible defects (P = 1.0). The sensitivity rate of two or more areas of redistribution was 11% (95% CI, 0.3%-48%), the specificity rate was 90%, and the positive and negative predictive values were 12.5% and 89%, respectively. CONCLUSION: Our study demonstrated no association between reversible defects on DTHAL/DMIBI and adverse cardiac events in moderate-risk patients undergoing elective vascular surgery.     

Trends in cardiac morbidity and mortality after endoluminal abdominal aortic aneurysm repair; discussion 999-1000

HYPOTHESIS: The adverse cardiac event rate following endoluminal abdominal aortic aneurysm (EAAA) repair has decreased as experience in performing the procedure has increased. Aneurysm complexity affects the rate of adverse cardiac events. DESIGN AND PATIENTS: Data from 173 consecutive patients undergoing EAAA repair from 2 successive periods were compared. There were 82 patients in the early group (group 1) and 91 patients in the later group (group 2). MAIN OUTCOME MEASURES: Myocardial infarction, congestive heart failure, unstable angina, major dysrhythmias, death. RESULTS: The cardiac event rate was 8.5% for group 1 vs 16.5% for group 2 (P =.16). Predictors of adverse cardiac events on multivariate analysis were the use of 4 or more graft extensions (P =.04), female sex (P =.01), and number of Eagle risk factors (P<.001). There were 2 postoperative deaths (2.4%) in group 1 and 4 (4.4%) in group 2 (P =.7). CONCLUSIONS: Following EAAA repair: (1) adverse cardiac events were found to correlate with use of 4 or more graft extensions, female sex, and the number of Eagle risk factors; (2) cardiac morbidity and mortality remain significant despite greater experience and improved technology; and (3) operative mortality remains acceptably low.     

Endovascular abdominal aortic aneurysm repair with general versus local anesthesia: a comparison of cardiopulmonary morbidity and mortality rates

PURPOSE: The purpose of this study was to compare the cardiopulmonary morbidity and mortality rates after endovascular abdominal aortic aneurysm (EAAA) repair with local anesthesia (LA) with intravenous sedation versus general anesthesia (GA). METHODS: Data from patients who underwent elective infrarenal EAAA repair between June 1996 and October 2000 were retrospectively reviewed. Patients with two or more Eagle clinical cardiac risk factors were considered to be at increased risk for a major postoperative cardiac event. Univariate and multivariate analyses for major cardiac and pulmonary morbidity and mortality rates were analyzed with respect to anesthetic type (GA versus LA), age, size of aneurysm, mean number of Eagle risk factors, and presence of two or more cardiac risk factors. RESULTS: Two hundred twenty-nine patients underwent EAAA repair. The GA (158 patients) and LA (71 patients) groups were significantly different with respect to mean age (73 versus 76 years; P =.01) and mean number of cardiac risk factors per patient (1.2 versus 1.6; P =.002). No difference was seen in the overall cardiopulmonary complication rate (13% for GA and 19% for LA; P =.3), pulmonary complication rate (3.8% for GA and 7% for LA; P =.3), or cardiopulmonary mortality rate (3.2% for GA and 2.8% for LA; P =.9). The major cardiac event rate was higher in patients with two or more Eagle risk factors (22%) versus those patients with one or less Eagle risk factors (3.4%; P <.001), irrespective of anesthetic type. In analysis of patients with one or less Eagle risk factors, no difference was seen in the major cardiac event rate by anesthetic type (3% for GA and 5% for LA; P =.6). Also, no difference was seen in major cardiac events in patients with two or more Eagle risk factors by anesthetic type (24% for GA and 22% for LA). On multivariate analysis, the mean number of Eagle risk factors per patient (P <.0001) and the presence of two or more Eagle risk factors were associated with major cardiac and cardiopulmonary complications, whereas age, size of AAA, and anesthetic type were not. CONCLUSION: No difference exists in overall cardiac and pulmonary morbidity and mortality rates after EAAA repair in comparison of GA and LA. The presence of two or more preoperative cardiac risk factors significantly increases the risk of a major postoperative cardiac event.     

Characteristics of patients at risk for perioperative myocardial infarction after infrainguinal bypass surgery: An exploratory study

Patients requiring infrainguinal bypass surgery often have diffuse atherosclerotic disease, and perioperative myocardial infarction (MI) is a potentially lethal complication that is not uncommon in these patients. To establish additional clinical characteristics that might be useful in identifying patients who require more extensive cardiac evaluation, we conducted an exploratory case-control study comparing 22 patients who had a perioperative MI following elective infrainguinal bypass surgery with 191 control subjects whose bypasses were uneventful. In addition to previously recognized risk factors (e.g., history of angina or prior MI), we examined the association of perioperative MI with (1) results of common preoperative laboratory tests and ECG, (2) preoperative use of certain medications, and (3) intraoperative factors that might be anticipated prior to surgery (e.g., duration of surgery or type of anesthesia). Perioperative MI was associated not only with a history of angina, prior MI, or coronary artery disease but also with the need for certain cardiac medications, higher white blood cell (WBC) counts, ST-segment depression, left bundle branch block, and lengthy surgical procedures. Multiple logistic regression analysis identified the following factors as being independently associated with perioperative MI: preoperative antiarrhythmic agents (odds ratio [OR]=26.4,p 0.006), nitrates (OR=8.4,p=0.006), calcium channel blockers (OR=5.5,p=0.04), and aspirin (OR=6.8,p <0.01) and ST-segment depression (OR=11.8,p=0.01), WBC count (OR=1.27/1000,p=0.005), and duration of surgery (OR=2.2/hr,p=0.0001). In patients undergoing infrainguinal bypass surgery, perioperative MI is associated not only with a history of previous cardiac events and ECG evidence of ischemia but also with regular use of certain cardiac medications, higher WBC counts, and longer surgical procedures. Incorporation of these variables into current methods of risk assessment might improve their predictive value sufficiently to provide an objective, inexpensive means of distinguishing patients who warrant extensive preoperative cardiac evaluation from those who do not.We are indebted to Maryann Barry, RN, for helping to collect the preoperative ECG reports and to Timothy Heeren, PhD, Boston University School of Public Health, for advice regarding statistical analysis.     

A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery.

OBJECTIVE: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). BACKGROUND: Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. METHODS: We studied 570 patients (mean age 69+/-9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. RESULTS: Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p=0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24, 95% CI: 0.10-0.70; p=0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.     

Cardiac assessment prior to vascular surgery: Is dipyridamole-sestamibi necessary?

Dipyridamole-sestamibi (PMIBI) is recommended prior to vascular surgery in patients with 1 Eagle criteria (Q waves, history of ventricular ectopy, diabetes, advanced age, and/or angina). To review our cardiac morbidity and mortality and the need for preoperative PMIBI, we reviewed 109 consecutive patients with a mean age of 59 years who underwent 145 elective major vascular procedures over a 1-year period. Seventy patients (with a mean of 0.8 Eagle criteria) underwent 92 vascular procedures without preoperative PMIBI and without coronary revascularization. Thirty-one patients (with a mean of 1.1 Eagle criteria) underwent 39 procedures without coronary revascularization following PMIBI, which showed reversible ischemia in seven and a fixed defect in 10; findings were normal in 14. Preoperative coronary bypass or angioplasty was limited to eight patients (14 procedures, mean of 1.6 Eagle criteria) who had unstable angina with (2 patients) or without (6 patients) acute myocardial infarction. There were four perioperative myocardial infarctions (2.8%), seven cardiac events overall (4.8%), and one cardiac death (0.7%). Three (43%) of the seven cardiac events occurred in patients with a normal scan or fixed defect on PMIBI imaging. In the absence of unstable angina, PMIBI had a sensitivity of only 25% and a specificity of 80% of cardiac events. We conclude that among patientswithout severe cardiac symptoms (1) PMIBI has a very limited ability to identify patients at risk for cardiac complications, and (2) preoperative PMIBI is neither necessary nor cost-effective.Supported in part by a grant from the Harbor-UCLA Medical Center Research and Education Institute.Presented at the Fourteenth Annual Meeting of the Southern California Vascular Surgical Society, September 15–17, 1995, La Jolla, Calif.     

An Abnormal Dipyridamole Thallium/Sestamibi Fails to Predict Long-term Cardiac Events in Vascular Surgery Patients

Recent data demonstrate that dipyridamole-thallium (DTHAL) and sestamibi (DMIBI) are not predictive of adverse perioperative cardiac events in moderate-risk patients (one or more Eagle risk factors) undergoing major elective vascular surgery. Less data are available regarding the ability of DTHAL/DMIBI to predict adverse cardiac events on long term follow-up. We sought to determine whether an abnormal DTHAL/DMIBI is predictive of adverse cardiac events on long-term follow-up in moderate-risk patients undergoing major elective vascular surgery. Patients were enrolled prospectively between June 1997 and June 1999 at West Los Angeles VA and Harbor-UCLA Medical Centers. Adverse cardiac events were defined as congestive heart failure (CHF), myocardial infarction (MI), unstable angina (USA), and ventricular arrhythmias. Follow-up was obtained via clinic visits, telephone calls, and chart review. We studied 75 patients (76% male, 24% female) with a mean age of 65 years. Operative procedures were primarily femorodistal (83%) and aortic (16%). DTHAL/DMIBI results were normal in 35 patients (47%), demonstrated reversible ischemia in 26 (35%), and showed a fixed defect alone in 14 (18%). From the follow-up results of this study we conclude that there is no association between a reversible ischemia or an abnormal (fixed or reversible) DTHAL/DMIBI and adverse cardiac events or mortality on long-term follow-up in moderate-risk patients who have undergone major vascular surgery.     

Preoperative and intraoperative predictors of postoperative morbidity, poor graft function, and early rejection in 190 patients undergoing liver transplantation

HYPOTHESIS: Preoperative and intraoperative variables predict in part adverse outcome after liver transplantation. DESIGN: Prospective, blinded, cohort study. SETTING: Tertiary care hospital. SUBJECTS: A total of 190 adult patients undergoing primary liver transplantation. MAIN OUTCOME MEASURE: Adverse outcome was prospectively defined as either in-hospital death or prolonged postoperative hospitalization (>14 days) associated with morbidity. Potential preoperative and intraoperative risk factors were collected. Associations were tested by univariate analysis followed by multivariate analysis in which preoperative factors were entered before intraoperative factors. RESULTS: Adverse outcome occurred in 44.7% of patients. Incidences of other complications were as follows: in-hospital mortality (8.4%), primary graft nonfunction (4.2%), poor early graft function (1.1%), and early rejection (31.2%). Univariate predictors of adverse outcome were United Network for Organ Sharing status (P =.003), Child-Turcotte-Pugh score (P =.02), POSSUM physiological score (P =.002), recipient age (P =.01), preoperative serum high-density lipoprotein cholesterol level (P =.03), preoperative serum creatinine level (P =.002), preoperative serum total IgG level (P =.004), duration in hospital preoperatively (P =.03), operative duration (P<.001), allogeneic erythrocyte transfusions (P<.001), total intraoperative fluids (P =.002), and use of inotropic agents (P =.01). In the final multivariate model, predictors of adverse outcome were United Network for Organ Sharing status (P =.03), recipient age (P =.002), and total intraoperative fluids (P =.04). Most patients who died or had a prolonged hospitalization exhibited dysfunction of more than 1 organ system, including pulmonary, renal, and infectious complications. CONCLUSIONS: Adverse outcome occurs frequently after liver transplantation, usually involves multiple organ systems, and is predicted in part by several preoperative and intraoperative factors.     

Factors affecting long-term mortality after endovascular repair of abdominal aortic aneurysms

HYPOTHESIS: Endovascular repair of abdominal aortic aneurysms has made considerable advancements with respect to perioperative mortality. However, fewer data are available regarding factors affecting long-term mortality, including the impact of adverse perioperative cardiac events. Perioperative clinical cardiac risk factors are significant predictors of long-term mortality.Design, Setting, and PATIENTS: Retrospective review of a prospective database of 468 patients who underwent endovascular abdominal aortic aneurysm repair from June 3, 1996, to January 31, 2005. MAIN OUTCOME MEASURES: Preoperative, intraoperative, and postoperative factors were analyzed using multivariate Cox proportional hazards models to identify statistically significant independent predictors of long-term survival (beyond 30 days and after discharge from the hospital). RESULTS: The mean age was 74 years, and 90% of the patients were male. Median follow-up was 2.57 years (interquartile range, 0.92-4.06 years). The leading cause of death was cardiac in nature. On multivariate analysis, the number of preoperative clinical cardiac risk factors (P < .001), spending 2 or more days in the intensive care unit (P < .001), and having an ST-segment elevation myocardial infarction (P < .001) were predictors of decreased long-term survival. Of note, having a perioperative non-ST-segment elevation myocardial infarction was not predictive of decreased survival (P = .09). CONCLUSIONS: Adverse cardiac events are the leading cause of long-term mortality following endovascular repair of abdominal aortic aneurysms. Preoperative clinical cardiac risk factors are significant predictors of long-term mortality, as are a prolonged intensive care unit stay and a perioperative ST-segment elevation myocardial infarction. A perioperative non-ST-segment elevation myocardial infarction did not influence long-term outcome.     

Electrocardiographic exercise stress testing for cardiac risk assessment in patients undergoing noncardiac surgery

BACKGROUND: The value of exercise electrocardiography in the prediction of perioperative cardiac risk has yet to be defined. This study was performed to determine the predictive value of exercise electrocardiography as compared with clinical parameters and resting electrocardiography. METHODS: A total of 204 patients at intermediate risk for cardiac complications prospectively underwent exercise electrocardiography before noncardiac surgery. Of these, 185 were included in the final evaluation. All patients underwent follow-up evaluation postoperatively by Holter monitoring for 2 days, daily 12-lead electrocardiogram, and creatine kinase, creatine kinase MB, and troponin-T measurements for 5 days. Cardiac events were defined as cardiac death, myocardial infarction, minor myocardial cell injury, unstable angina pectoris, congestive heart failure, and ventricular tachyarrhythmia. Potential risk factors for an adverse event were identified by univariate and multivariate logistic regression analysis. RESULTS: Perioperative cardiac events were observed in 16 patients. There were 6 cases of myocardial infarction and 10 cases of myocardial cell injury. The multivariate correlates of adverse cardiac events were definite coronary artery disease (odds ratio, 8.8; 95% confidence interval [CI], 1.1--73.1; P = 0.04), major surgery (odds ratio, 4.7; 95% CI, 1.3--16.3; P = 0.02), reduced left ventricular performance (odds ratio, 2.0; 95% CI, 1.1--3.8; P = 0.03), and ST-segment depression of 0.1 mV or more in the exercise electrocardiogram (odds ratio, 5.2; 95% CI, 1.5--18.5; P = 0.01). A combination of clinical variables and exercise electrocardiography improved preoperative risk stratification. CONCLUSIONS: This prospective study shows that a ST-segment depression of 0.1 mV or more in the exercise electrocardiogram is an independent predictor of perioperative cardiac complications.     

Recent Preoperative Myocardial Infarction Increases the Risk of Surgery for Unstable Angina

Patients with postinfarction angina undergoing surgery for unstable angina face an increased risk of operative mortality. Between January 1982 and December 1987, clinical, angiographic, and operative data was collected prospectively in 588 unstable patients with a prior myocardial infarction within 30 days of surgery (MI) and 5951 unstable patients without preoperative damage (NONMI). MI patients were characterized as being older (age greater than or equal to 70 years: MI, 19.7%; NONMI, 11.6%; p less than 0.001) and having more left ventricular dysfunction (left ventricular ejection fraction less than 40%: MI, 34.8%; NONMI, 26.4%; p less than 0.001). Semi-elective surgery was performed in 82.0% of NONMI patients while 76.9% of MI patients underwent urgent surgery. Operative mortality was increased in MI patients (MI, 11.1%; NONMI, 4.0%; p less than 0.001) which was related to the extent of preoperative MI (non-Q wave, 8.3%; Q wave, 17.5%; p less than 0.001). Stepwise logistic regression analysis identified preoperative MI as an independent risk variable of operative mortality for unstable angina. Separate multivariate analyses were performed to identify the independent predictors for MI and NONMI patients. The multivariate predictors of operative death for MI patients were left ventricular dysfunction, reoperative coronary surgery, nonuse of the internal mammary, age, transmural MI (relative risk 2.11 vs non-Q wave infarction) and left main stenosis. For NONMI patients, the independent variables were urgent operation, left ventricular dysfunction, reoperation, female gender, left main stenosis, and age. The results of this study indicate that recent preoperative MI adversely influences the surgical results in patients with unstable angina. Alternative treatment strategies are warranted for high risk patients, particularly those with transmural MIs and impaired ventricular function.     

Revascularization of multiple bypassable extended right coronary arteries

BACKGROUND: Extended right coronary arteries are not uncommon in coronary surgery. They can be revascularized optionally either by conventional single or complete multiple bypassing. However, there are still no objective data showing the superiority or appropriateness of one of these methods over the other. METHODS: Extended right coronary arteries were identified by preoperative angiographic scoring and randomized to multiple-bypassing (group A; n = 32) or single-bypassing (group B; n = 32) groups. Four parameters that show the completeness of right coronary territory revascularization were evaluated and compared between the 2 groups. RESULTS: Although overall perioperative ischemic events seemed to increase in the single-bypass group (P =.0059), half of them were reversible, and there were no statistical differences between the definitive perioperative ischemic event rates, namely, infarction rates, and the remaining 3 parameters of the groups. Logistic regression analysis showed that preoperative left ventricular dysfunction (ejection fraction <50%) was the most significant predictor of these perioperative ischemic events. Hence, the subgroups of patients with left ventricular dysfunction were also evaluated (subgroup A, n =13; subgroup B, n = 12). Overall perioperative ischemic event (P =.001), definitive perioperative ischemic event (infarction; P =.0324), and consequent right ventricular dysfunction (P =.0324) rates were significantly higher in the single-bypass subgroup. Postoperative reperfusion status and graft patency rates of the right coronary territory did not change with the different revascularization methods. CONCLUSIONS: Complete revascularization of extended right coronary arteries did not seem advantageous over its conventional operation in patients with normal ventricular function; however, in patients with poor ventricular function (ejection fraction <50%), it prevented perioperative ischemic events in the right coronary territory and the consequent functional impairment that appeared with conventional operation.     

Factors affecting saphenous vein graft patency: clinical and angiographic study in 1402 symptomatic patients operated on between 1977 and 1999

BACKGROUND: The purpose of this study was to find the preoperative and intraoperative factors that affect vein graft patency. METHODS: A total of 3715 graft angiograms in 1607 patients were studied for recurrence of angina. The preoperative patient characteristics and intraoperative variables were prospectively collected from patients who had primary coronary artery bypass grafting during the period from 1977 to 1999. A total of 1339 (83%) patients were male, with a mean age of 59 years. The mean period from operation to reangiogram was 99 months. The saphenous vein was grafted to the left anterior descending artery in 557 (15%), to the diagonal artery in 669 (18%), to the obtuse marginal artery in 1300 (35%), to the right coronary artery in 409 (11%), and to the posterior descending artery in 780 (21%) cases. Graft failure was defined as >or=80% stenosis. RESULTS: During the course of the study, 2266 (61%) grafts were patent, and 1449 (39%) had failed. The patient variables that significantly reduced graft patency were a younger age (P <.001) and an ejection fraction <30% (P =.047). Operative variables associated with reduced graft patency were small coronary artery diameter (P <.001), large conduit diameter (P =.001), and the coronary artery grafted (lowest patency in the right coronary artery and maximum patency in the left anterior descending artery territory; P =.002). The interval from operation to repeat angiogram (P <.001, with 78% patent at 1 year, 78% at 5 years, 60% at 10 years, and 50% at 15 years) and the year in which the operation was performed (more recent operations had better patency; P <.001) significantly affected graft patency. CONCLUSIONS: Saphenous vein graft patency improved over the course of the study. The best results were obtained in older patients with good left ventricular function. Large-caliber arteries on the left system, when grafted with a small-diameter vein, were associated with the best outcome.     

High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: an angiographic examination

The prevalence of coronary artery stenosis (CAS) at the initiation of renal replacement therapy (RRT) in patients with chronic kidney disease (CKD) and no previous history of angina and/or myocardial infarction (MI) has not been fully elucidated. The prevalence of significant CAS was evaluated in 30 asymptomatic stage 5 CKD patients without a history of angina and/or MI by coronary angiography at the initiation of RRT. The correlations of various parameters with the prevalence of CAS were also examined. Atherosclerotic surrogate markers, including intima-media thickness of carotid artery and ankle-brachial BP index (ABI), were also evaluated. Significant CAS (>50% stenosis) was seen in 16 (53.3%) of 30 asymptomatic CKD patients on coronary angiography at the start of RRT. Stress cardiac scintigraphy was not effective for detecting hidden cardiac ischemia among the CKD patients. Univariate analysis showed that diabetes (P = 0.01), left ventricular mass index (P = 0.04), hyperlipidemia (P = 0.04), total cholesterol (P = 0.02), LDL cholesterol (P < 0.01), intima-media thickness (P = 0.04), and fibrinogen (P = 0.01) were positively correlated with the presence of CAS, whereas ABI (P < 0.01) showed a negative correlation with CAS. Stepwise logistic regression analysis revealed that diabetes and fibrinogen were significant and independent risk factors for CAS in asymptomatic CKD patients who started RRT. The results clearly demonstrated that despite the absence of cardiac events, stage 5 CKD patients are already in a very high risk group for CAS at the initiation of RRT, which was also closely associated with a significant decrease in ABI.     

Correlation between prior coronary revascularization and perioperative cardiac events in patients for noncardiac surgery

We evaluated the influence of interval between prior coronary revascularization and subsequent noncardiac surgery on perioperative cardiac events. We retrospectively identified 162 consecutive patients with previous revascularization procedures who had undergone noncardiac surgery. Postoperative cardiac complications occurred in 10 (6.2%) patients, cardiac death in 1 patient, and significant arrhythmia in 3 patients. These patients had higher rates of unstable angina, myocardial infarction within 3 months, cerebrovascular disease, peripheral vascular disease, renal dysfunction (Cr > or = 1.9 mg.dl-1) and higher preoperative risk scores as described by the Cleveland Clinic (P < 0.05). Also, the incidence of cardiac complications increased when noncardiac surgery was performed within 1 week of previous percutaneous transluminal coronary angioplasty (PTCA) and in more than 5 years after coronary artery bypass grafting or PTCA (P < 0.05). Although PTCA is widely accepted, especially in Japan, early lesion progression was observed during the first several days and atherosclerotic progression was apparent in more than 5 years after the procedure. Therefore, the time between coronary revascularization and noncardiac surgery, as well as atherosclerotic risk factors, is important in evaluating patients with history of previous revascularization procedures.     

Comparative early and late cardiac morbidity among patients requiring different vascular surgery procedures

Purpose: The evaluation of coronary artery disease (CAD) in patients undergoing vascular surgery can provide information with respect to perioperative and long-term risk for CAD-related events. However, the extent to which the required surgical procedure itself imparts additional risk beyond that dictated by the presence of CAD determinants remains in question. The purpose of this study was to quantify the relative contributions of specific vascular procedures and CAD markers on perioperative and long-term cardiac risk.Methods: The study cohort comprised 547 patients undergoing vascular surgery from two medical centers who underwent clinical evaluation, dipyridamole thallium testing, and either aortic (n = 321), infrainguinal (n = 177), or carotid (n = 49) vascular surgery between 1984 and 1991. Perioperative and late cardiac risk of fatal or nonfatal myocardial infarction (MI) was compared for the three procedures before and after adjustment for the influence of comorbid factors. These adjusted estimates may be regarded as the component of risk because of type of surgery.Results: Perioperative MI occurred in 6% of patients undergoing aortic and carotid artery surgery, and in 13% of patients undergoing infrainguinal procedures (p = 0.019). Significant (p < 0.05) predictors of MI were history of angina, fixed and reversible dipyridamole thallium defects, and ischemic ST depression during testing. Although patients undergoing infrainguinal procedures exhibited more than twice the risk for perioperative MI compared with patients undergoing aortic surgery (relative risk: 2.4[1.2 to 4.5, p = 0.008]), this value was reduced to insignificant levels (1.6[0.8 to 3.2, p = 0.189]) after adjustment for comorbid factors. There was little change in comparative risk between carotid artery and aortic procedures before (1.0[0.3 to 3.6, p = 0.95]) or after (0.6[0.2 to 2.3, p = 0.4]) covariate adjustment. The 4-year cumulative event-free survival rate was 90% ± 2% for aortic, 74% ± 5% for infrainguinal, and 78% ± 7% for carotid artery procedures (p = 0.0001). Predictors of late MI included history of angina, congestive heart failure, diabetes, fixed dipyridamole thallium defects, and perioperative MI. Patients undergoing infrainguinal procedures exhibited a threefold greater risk for late events compared with patients undergoing aortic procedures (relative risk: 3.0[1.8 to 5.1, p = 0.005]), but this value was reduced to 1.3(0.8 to 2.3, p = 0.32) after adjustment. Long-term risk among patients undergoing carotid artery surgery was less dramatically altered by risk factor adjustment.Conclusion: In current practice, among patients referred for dipyridamole testing before operation, observed differences in cardiac risk of vascular surgery procedures may be primarily attributable to readily identifiable CAD risk factors rather than to the specific type of vascular surgery. Thus the cardiac and diabetic status of patients should be given careful consideration whenever possible, regardless of surgical procedure to be performed. (J V ASC S URG 1995;21:935-44.)     

Impact of Cardiac Comorbidity on Early Outcomes after Pancreatic Resection

Background

In patients undergoing pancreatic resection (PR), identification of subgroups at increased risk for postoperative complications can allow focused interventions that may improve outcomes.

Study Design

Patients undergoing PR from 2005–2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database and categorized as having any history of cardiac disease (angina, congestive heart failure (CHF), myocardial infarction (MI), cardiac stent, or bypass) or as having acute cardiac disease (symptoms of CHF or angina within 30 days or MI within 6 months). These variables were utilized to examine the relationship between cardiac disease and outcomes after PR.

Results

The rate of serious complications and perioperative mortality in patients with any history of cardiac disease vs. those without was 34 vs. 24 % (p?<?0.001) and 4.5 vs. 2.0 % (p?<?0.001), respectively, and in patients with acute cardiac disease compared to patients without was 37 vs. 25 % (p?<?0.001) and 8.6 vs. 2.2 % (p?<?0.001), respectively. In multivariate analysis, the two cardiac disease variables remained associated with mortality.

Conclusions

In patients undergoing PR, cardiac disease is a significant risk factor for adverse outcomes. These observations are critical for meaningful informed consent in patients considering pancreatectomy.     

Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. European Collaborators on Stent/graft techniques for aortic aneurysm repair

OBJECTIVE: The EUROSTAR (European Collaborators on Stent/graft techniques for aortic aneurysm repair) Registry was established in 1996 to collect data on the outcome of treatment of patients with infrarenal aortic aneurysms with endovascular repair. To date, 88 European centers of vascular surgery have contributed. The purpose of the study was to evaluate the results of this treatment in the medium term (up to 4 years) according to the analysis of "hard" or primary end points of rupture, late conversion, and death. PATIENTS AND METHODS: Patients with aortic aneurysms suitable for endovascular aneurysm repair were notified to the EUROSTAR Data Registry Centre before treatment to eliminate bias due to selective reporting. The following information was collected on all patients: (1) demographic details and the anatomic characteristics of their aneurysms, (2) details of the endovascular device used, (3) complications encountered during the procedure and the immediate outcome, (4) results of contrast enhanced computed tomographic imaging at 3, 6, 12, and 18 months after operation and at yearly intervals thereafter, and (5) all adverse events. Life table analysis was performed to determine the cumulative rates of (1) death from all causes, (2) rupture, and (3) late conversion to open repair. Risk factors for rupture and late conversion were identified through regression analysis. RESULTS: By March 2000, 2464 patients had been registered, and their mean duration of follow-up was 12.19 months (SD, 12.3 months). There were 14 patients with confirmed rupture of their aneurysms. The cumulative rate (risk) of rupture was approximately 1% per year. Emergency surgery was undertaken in 12 (86%) patients, of whom five (41.6%) survived. Two patients who were not treated surgically also died, which resulted in an overall death rate of 64.5% (9/14) of the patients. Significant risk factors for rupture were proximal type I endoleak (P =.001), midgraft (type III) endoleak (P =.001), graft migration (P =.001), and postoperative kinking of the endograft (P =.001). Forty-one patients underwent late conversion to open repair with a perioperative mortality rate of 24.4% (10/41). The cumulative rate (risk) of late conversion was approximately 2.1% per year. Risk factors (indications) for late conversion were proximal type I endoleak (P =. 001), midgraft (type III) endoleak (P =.001), type II endoleak (P =. 003), graft migration (P =.001), graft kinking (P =.001), and distal type I endoleak (P =.001). CONCLUSIONS: Endovascular repair of infrarenal aortic aneurysms with the first- and second-generation devices that predominated in this study was associated with a risk of late failure, according to an analysis of observed hard end points of 3% per year. Action taken to address the risk factors identified by the study may improve results in the future.     

Predictive factors for perioperative blood transfusions in rectal resection for cancer: A multivariate analysis of a group of 212 patients

BACKGROUND. In colorectal cancer surgery, allogeneic blood transfusions have reportedly been associated with higher rates of postoperative complications and tumor recurrence. However, because of the increased cost of alternative types of blood transfusions (eg, the use of autologous blood or erythropoietin administration), their routine use cannot be recommended. This study evaluated the risk factors for perioperative blood transfusions in resection for rectal cancer in order to identify patients who could benefit from these methods. METHODS. From 1990 to 1997, 212 consecutive patients who underwent elective rectal resection for cancer were reviewed. The associations between perioperative heterologous blood transfusion and 18 patient-, tumor-, surgical-, and treatment-related variables were assessed by univariate and multivariate analysis. RESULTS. Of the 212 patients, 72 (34%) received transfusions. Multivariate analysis revealed that 5 preoperative variables were significant risk factors for perioperative blood transfusion: age > 65 years (P =.03), body mass index > 27 kg/m(2) (P =.04), preoperative hemoglobin < or = 12.5 g/dL (P <.0001), American Society of Anesthesiologists status > 2 (P =.024), and additional surgical procedures (P =.018). In patients with anemia, the risk of transfusion was at least 47% in patients with 1 other risk factor or more. In nonanemic patients, the risk of transfusion was under 11% in patients with 1 risk factor or none, but increased to 47% in those with 2 or more risk factors. CONCLUSIONS. Our analysis of risk factors for perioperative blood transfusion in rectal resection for cancer must be considered to constitute guidelines for a more responsible use of the expensive alternatives to allogeneic blood transfusion.