Preoperative management of the patient with coronary artery disease before abdominal aortic surgery

Coronary artery disease accounts for more than half of the morbidity and mortality associated with abdominal aortic surgery. To improve the results of vascular surgery, the risk of perioperative cardiac ischemia should be evaluated in each patient. Routine coronary angiography demonstrated severe correctable coronary artery disease in 14% of patients who had no history or electrocardiographic evidence of coronary artery disease. Exercise testing before abdominal aortic aneurysm repair will identify patients at high risk of cardiac ischemia. Dipyridamole-thallium imaging will identify high-risk patients before surgery for aortoiliac occlusive disease. Some patients with symptomatic coronary disease who are at extremely high risk should undergo preoperative coronary revascularization. Others should have their vascular surgery deferred, because their cardiac risk may exceed the anticipated benefit of the vascular surgery. Patients at moderate risk may need more intensive intraoperative monitoring. Patients without evidence of cardiac ischemia with stress may undergo vascular surgery with a low risk of perioperative cardiac ischemia. Finally, patients who have evidence of ischemic heart disease should be considered for coronary revascularization following successful vascular repair in order to prolong their survival.     

Perioperative Cardiac Risk Stratification and Modification in Abdominal Aortic Aneurysm Repair

Cardiovascular complications are important causes of morbidity and mortality following vascular surgery. Adequate preoperative risk assessment and perioperative management may modify postoperative mortality and morbidity and improve long-term prognosis. The objective of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative management of patients undergoing noncardiac surgery, focusing specifically on abdominal aortic aneurysm (AAA) repair.

Clinical markers combined with ECG and surgical risk assessment can effectively divide patients in a truly low-risk, intermediate and high-risk population. Low-risk patients can probably be operated on without additional cardiac testing. Notably, due to the surgical risk, AAA patients are never low-risk patients. Intermediate-risk and high-risk patients are referred for cardiac testing to exclude extensive stress induced myocardial ischemia, as beta-blockers provide insufficient myocardial protection in this case and preoperative coronary revascularization might be considered. Whether patients at intermediate risk without ischemic heart disease should be treated with statins and/or beta-blockers is still controversial. In high-risk patients, it is strongly advised to administer beta-blockers with heart rate determined dose adjustment, while the effects of preoperative revascularization remain subject to debate.     

Perioperative cardiac risk stratification and modification in abdominal aortic aneurysm repair

Cardiovascular complications are important causes of morbidity and mortality following vascular surgery. Adequate preoperative risk assessment and perioperative management may modify postoperative mortality and morbidity and improve long-term prognosis. The objective of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative management of patients undergoing noncardiac surgery, focusing specifically on abdominal aortic aneurysm (AAA) repair. Clinical markers combined with ECG and surgical risk assessment can effectively divide patients in a truly low-risk, intermediate and high-risk population. Low-risk patients can probably be operated on without additional cardiac testing. Notably, due to the surgical risk, AAA patients are never low-risk patients. Intermediate-risk and high-risk patients are referred for cardiac testing to exclude extensive stress induced myocardial ischemia, as beta-blockers provide insufficient myocardial protection in this case and preoperative coronary revascularization might be considered. Whether patients at intermediate risk without ischemic heart disease should be treated with statins and/or beta-blockers is still controversial. In high-risk patients, it is strongly advised to administer beta-blockers with heart rate determined dose adjustment, while the effects of preoperative revascularization remain subject to debate.     

The impact of a cardioprotective protocol on the incidence of cardiac complications after aortic abdominal surgery

We analyzed a local database including 468 consecutive patients who underwent elective aortic abdominal surgery over an 8-yr period in a single institution. A new cardioprotective perioperative protocol was introduced in January 1997, and we questioned whether perioperative cardiac outcome could be favorably influenced by the application of a stepwise cardiovascular evaluation based on the American College of Cardiology/American Heart Association guidelines and by the use of antiadrenergic drugs. Clonidine was administered during surgery, and beta-blockers were titrated after surgery to achieve heart rates less than 80 bpm. We compared data of two consecutive 4-yr periods (1993-1996 [control period] versus 1997-2000 [intervention period]). Implementation of American College of Cardiology/American Heart Association guidelines was associated with increased preoperative myocardial scanning (44.3% vs 20.6%; P < 0.05) and coronary revascularization (7.7% vs 0.8%; P < 0.05). During the intervention period, there was a significant decrease in the incidence of cardiac complications (from 11.3% to 4.5%) and an increase in event-free survival at 1 yr after surgery (from 91.3% to 98.2%). Multivariate regression analysis showed that the combined administration of clonidine and beta-blockers was associated with a decreased risk of cardiovascular events (odds ratio, 0.3; 95% confidence interval, 0.1-0.8), whereas major bleeding, renal insufficiency, and chronic obstructive pulmonary disease were predictive of cardiac complications. In conclusion, cardiac testing was helpful to identify a small subset of high-risk patients who might benefit from coronary revascularization. Sequential and selective antiadrenergic treatments were associated with improved postoperative cardiac outcome. IMPLICATIONS: Implementation of American College of Cardiology/American Heart Association guidelines and use of antiadrenergic drugs were associated with better cardiac outcomes after major vascular surgery.     

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.)     

Postoperative outcomes for patients undergoing elective revascularization for critical limb ischemia and intermittent claudication: a subanalysis of the Coronary Artery Revascularization Prophylaxis (CARP) trial

OBJECTIVE: To determine the perioperative mortality, myocardial infarction rate, and long-term survival of patients with critical limb ischemia (CLI) compared with those with intermittent claudication (IC) within a cohort selected for significant coronary artery disease, a secondary analysis was conducted of a prospective, randomized, multicenter trial of Coronary Artery Revascularization Prophylaxis (CARP) before peripheral vascular surgery. This multicenter trial was sponsored by the Cooperative Studies Program of the Department of Veterans Affairs. METHODS: Of the 510 patients enrolled in the CARP trial and randomized to coronary revascularization or no revascularization before elective vascular surgery, 143 had CLI and 164 had IC as an indication for lower limb revascularization; >95% of each group were men. The presence of coronary artery disease was determined by cardiac catheterization. Eligible patients had at least one treatable coronary lesion of > or =70%. Those with significant left main disease, ejection fraction of <20%, and aortic stenosis were excluded. Patients were randomized to coronary artery disease revascularization or no revascularization before vascular surgery and followed for mortality and morbidity perioperatively and for a median of 2.7 years postoperatively. Medical treatment of coronary artery disease was pursued aggressively. RESULTS: Patients with IC had a longer time from randomization to vascular surgery (p = .001) and more abdominal operations (p < .001). Patients with CLI had more urgent operations (p = .006), reoperations (p < .001), and limb loss (p = .008) as well as longer hospital stays (p < .001). The IC group had more perioperative myocardial infarctions (CLI, 8.4%; IC, 17.1%; p = .024), although perioperative mortality was similar (CLI, 3.5%; IC, 1.8%; p = .360). In follow-up, the IC group also had numerically more myocardial infarctions (CLI, 16.8%; IC, 25%; p = .079), but mortality was not different (CLI, 21%; IC, 22%; p = .825). Coronary artery revascularization did not lower perioperative or long-term mortality in either group. CONCLUSIONS: Our data indicate that patients with significant coronary artery disease and either CLI or IC can undergo vascular surgery with low mortality and morbidity, and these results are not improved by coronary artery revascularization before vascular surgery. Furthermore, when selected for the presence of symptomatically stable, severe coronary artery disease, there is no difference in long-term survival between patients with CLI and IC. Finally, the better-than-predicted outcomes for these patients with advanced systemic atherosclerosis may be due to aggressive medical management with beta-blockers, statins, and acetylsalicylic acid.     

Selection of patients for cardiac evaluation before peripheral vascular operations

Purpose: This study evaluated the value of preoperative cardiac screening with dipyridamole thallium scintigraphy and radionuclide ventriculography in vascular surgery patients.Methods: From July 1, 1989, to Dec. 31, 1991, we routinely (irrespective of the patient's cardiac history or symptomatology) performed dipyridamole thallium scintigraphy (DTS) and radionuclide ventriculography (RVG) in 394 patients being considered for an elective vascular operation. Patients with reversible defects on DTS underwent coronary arteriography.Results: DTS results were normal in 146 patients (37%), showed a fixed defect in 75 (19%), and showed a reversible defect in 173 (44%). Patients with and without a history of angina or myocardial infarction had identical rates of reversible defects. Normal left ventricular function (>50%) was noted in 76% of the patients; 17% had moderate dysfunction (35% to 50%) and 7% had a low ejection fraction (<35%). The finding of severe coronary artery disease led to cardiac revascularization in 17 patients who had no prior history of cardiac disease and in 13 patients with a history of angina or myocardial infarction. Two deaths and nine major complications were associated with coronary arteriography and cardiac revascularization. Vascular procedures (144 aortic, 53 carotid, 146 infrainguinal) were ultimately performed in 343 patients, with a mortality rate of 1.7% (3.5% aortic, 0% carotid, and 0.7% infrainguinal bypass). The nonfatal perioperative myocardial infarction rate was 2.0%. We monitored all 394 patients for cardiovascular events, with a mean follow-up of 40 months. Patients who underwent cardiac revascularization had a 4-year survival rate of 75%, which was similar to those with a normal DTS. Late cardiac events were significantly more frequent in patients who had either a reversible DTS or RVG <35%.Conclusions: Routine cardiac screening of vascular surgery patients had similar impact on patients irrespective of their prior history or current symptoms suggesting coronary artery disease. Routine screening did not result in substantial benefit. Screening studies such as DTS or RVG may be most useful as part of an overall risk versus benefit assessment in patients without active symptoms of coronary artery disease who have less compelling indications for vascular intervention (claudication, moderate-sized aortic aneurysms, or asymptomatic carotid disease). (J Vasc Surg 1996;23:802-9.)     

Selective preoperative cardiac screening improves five-year survival in patients undergoing major vascular surgery: a cost-effectiveness analysis.

OBJECTIVE: To evaluate the long-term outcomes (5-year survival) and cost-effectiveness of selective coronary revascularization before major vascular surgery. DESIGN: A decision-tree model was constructed to compare the cost-effectiveness of four preoperative screening strategies from the perspective of the health care system. SETTING: Based on patient mortality, morbidity, and cost data from a literature review. PARTICIPANTS: Hypothetical cohort of patients scheduled for elective abdominal aortic aneurysm repair followed up over a 5-year period. INTERVENTIONS: Patients either proceeded directly to surgery or were screened using one of three possible preoperative screening strategies. In the first strategy, all patients were screened with a dipyridamole-thallium test. In the second strategy, all patients underwent coronary angiography. The third strategy, selective screening, first divided patients into high-, intermediate-, and low-risk groups using clinical criteria. High-risk patients underwent preoperative angiography. Intermediate-risk patients were screened noninvasively, and low-risk patients proceeded directly to surgery without further testing. MEASUREMENT AND MAIN RESULTS: Proceeding directly to vascular surgery resulted in the poorest 5-year survival rate (77.4%) compared with preoperative risk stratification followed by selective coronary revascularization, routine noninvasive testing (86.1%), selective testing (86.0%), and routine angiography (87.9%; p = 0.00). The incremental cost-effectiveness ratio for selective testing was significantly lower than for routine angiography ($44,800/years of life saved (YLS) v $93,300/YLS; p < 0.02). Routine noninvasive testing was not cost-effective. Thirty-day mortality was the same for all four strategies (p = 0.84). CONCLUSION: Selective screening before vascular surgery may improve 5-year survival and be cost-effective. Neither routine noninvasive testing nor routine angiography appears to be cost-effective compared with currently accepted medical therapies.     

Critical appraisal of cardiac risk stratification before elective vascular surgery

This study was undertaken to evaluate the efficacy of the cardiac risk stratification protocol proposed by the American College of Cardiology/American Heart Association (ACC/AHA) in predicting cardiac morbidity and mortality associated with elective, major arterial surgery. Cardiac risk stratification using ACC/AHA guidelines was done on 425 consecutive patients before 481 elective cerebrovascular (n = 146), aortic/inflow (n = 166), or infrainguinal (n = 169) procedures at an academic Veterans Affairs Medical Center. Cardiac risk was stratified as low, intermediate, or high based on clinical risk factors, such as, Eagle criteria, history of cardiac intervention, patient functional status, results of noninvasive cardiac stress testing, and coronary angiography with coronary revascularization performed when appropriate. Outcomes (myocardial infarction, unstable angina, congestive heart failure, ventricular arrhythmia, cardiac death, and mortality) within 30 days of surgery were compared between the various risk stratification groups. Univariate and multivariate analyses were used to identify clinically useful prognostic variables from the preoperative cardiac evaluation algorithm. Overall mortality (1.7%), cardiac death (0.4%), and adverse cardiac event (4.8%) rates were low, but cardiac death and morbidity were increased (p < 0.05) in high-risk stratified patients (3.4%, 11.9%) compared to intermediate (0%, 2.8%) and low (0%, 4.0%) cardiac risk groups. The presence of 3-vessel angiographic coronary artery occlusive disease was an independent predictor of cardiac morbidity, while inducible ischemia by cardiac stress imaging was not. Previous coronary revascularization was associated with increased mortality as was the development of a non-cardiac complication. Cardiac risk assessment identified 78 (18%) patients with indications for coronary angiography. Angiographic findings resulted in coronary artery intervention (9-angioplasty; 4-bypass grafting) in 13 (3%) patients who experienced no adverse cardiac events after the planned vascular surgery (15 procedures). Cardiac risk stratification using ACC/AHA guidelines can predict adverse cardiac events associated with elective vascular surgery; however, protocol modification by increased reliance on Eagle criteria and less use of cardiac stress testing can improve identification of the "highest risk" patients who may benefit from prophylactic coronary intervention.     

Long-term survival after vascular surgery: specific influence of cardiac factors and implications for preoperative evaluation

OBJECTIVE: We sought to identify specific determinants of long-term cardiac events and survival in patients undergoing major arterial operations after preoperative cardiac risk stratification by American College of Cardiology/American Heart Association guidelines. A secondary goal was to define the potential long-term protective effect of previous coronary revascularization (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) in patients with vascular disease. METHODS: Four hundred fifty-nine patients underwent risk stratification (high, intermediate, low) before 534 consecutive elective or urgent (<24 hours after presentation) open cerebrovascular, aortic, or lower limb reconstruction procedures between August 1996 and January 2000. Long-term follow-up (mean, 56 +/- 14 months) was possible in 97% of patients. The Kaplan-Meier method was used for survival data. Long-term prognostic variables were identified with the multivariate Cox proportional hazards model and contingency table analysis censoring early (<30 days) perioperative deaths. RESULTS: While 5-year survival was 72% for the overall cohort, cardiac causes accounted for only 24% of all deaths, and new cardiac events (myocardial infarction, congestive heart failure, arrhythmia, unstable angina, new coronary angiography, new CABG or PCI, cardiac death) affected only 4.6% of patients per year during follow-up. High cardiac risk stratification level (hazards ratio [HR], 2.2, 95% confidence interval [CI], 1.4-3.4), adverse perioperative cardiac events (myocardial infarction, congestive heart failure, ventricular arrhythmia; HR, 2.2; 95% CI, 1.2-4.1), and age (HR, 0.33; 95% CI, 0.2-0.6) were independently prognostic for latemortality. Preoperative cardiac risk levels also correlated with new cardiac event rates ( P < .01) and late cardiac mortality ( P = .02). Modestly improved survival in patients who had undergone CABG or PCI less than 5 years before vascular operations compared with those who had undergone revascularization 5 or more years previously and those at high risk without previous coronary intervention (73% vs 58% vs 62% 5-year survival; P = .02) could be demonstrated with univariate testing, but not with multivariate analysis. Type of operation, urgency, noncardiac complications, and presence of diabetes did not affect long-term survival. CONCLUSION: Despite cardiac events being a less common cause of late mortality after vascular surgery, perioperative cardiac factors (age, preoperative risk level, early cardiac complications) are the primary determinants of patient longevity. Patients undergoing more recent (<5 years) CABG or PCI before vascular surgery do not have an obvious survival advantage compared with patients at high cardiac risk without previous coronary interventions.     

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.     

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.     

Evaluation,Severity and Prognostic Significance of Silent Myocardial Ischaemia in Vascular Patients

This paper intends to make an update of recent publications and guidelines for evaluation in coronary symptom-free patients undergoing vascular surgery. It emphasizes the role of preoperative clinical evaluation that should identify the most appropriate testing, and treatment strategies to optimize care of the patient and avoid unnecessary testing in this era of cost containment. Selective preoperative coronary artery disease screening and revascularization achieve excellent perioperative and late results after high-risk vascular surgery. Supplemental preoperative evaluation is discussed (exercise ECG, stress echocardiography and stress tomoscintigraphy). Asymptomatic patients with good functional capacity can undergo intermediate-risk surgery without further non-invasive testing. Conversely, further noninvasive testing is often considered for patients with poor functional capacity or moderate functional capacity but higher-risk surgery especially for patients with 2 or more intermediate risk predictors. Additional testing may be considered on an individual basis for patients without clinical markers but with poor functional capacity prior to vascular surgery, particularly those with several minor clinical risk predictors. Because of a higher prevalence of silent myocardial ischaemia in diabetes mellitus, these patients require specific care. Until further data are available, indications for myocardial revascularization in the perioperative setting are similar to those in the ACC/AHA guidelines for use of myocardial revascularization in general. General practioners, cardiologists, angiologists, vascular surgeons and anaes-thesiologists should collaborate and aim to slow down the progression of atherosclerosis by giving their patients an optimum secondary cardiovascular prevention.     

Evaluation,severity and prognostic significance of silent myocardial ischaemia in vascular patients

This paper intends to make an update of recent publications and guidelines for evaluation in coronary symptom-free patients undergoing vascular surgery. It emphasizes the role of preoperative clinical evaluation that should identify the most appropriate testing, and treatment strategies to optimize care of the patient and avoid unnecessary testing in this era of cost containment. Selective preoperative coronary artery disease screening and revascularization achieve excellent perioperative and late results after high-risk vascular surgery. Supplemental preoperative evaluation is discussed (exercise ECG, stress echocardiography and stress tomoscintigraphy). Asymptomatic patients with good functional capacity can undergo intermediate-risk surgery without further non-invasive testing. Conversely, further noninvasive testing is often considered for patients with poor functional capacity or moderate functional capacity but higher-risk surgery especially for patients with 2 or more intermediate risk predictors. Additional testing may be considered on an individual basis for patients without clinical markers but with poor functional capacity prior to vascular surgery, particularly those with several minor clinical risk predictors. Because of a higher prevalence of silent myocardial ischaemia in diabetes mellitus, these patients require specific care. Until further data are available, indications for myocardial revascularization in the perioperative setting are similar to those in the ACC/AHA guidelines for use of myocardial revascularization in general. General practitioners, cardiologists, angiologists, vascular surgeons and anaesthesiologists should collaborate and aim to slow down the progression of atherosclerosis by giving their patients an optimum secondary cardiovascular prevention.     

Coronary artery disease in aortic surgery

The incidence of coronary artery disease in patients coming to aortic surgery and the impact of aggressive preoperative cardiac catheterization and myocardial revascularization was prospectively analyzed in 59 patients. Seventy-five percent of patients had at least one-vessel involvement, and 32% had three-vessel or left main involvement. Patients with electrocardiographic evidence of coronary artery disease had at least one-vessel involvement 84% of the time and three-vessel, left main involvement 36% of the time. Sixty-four percent of patients with no preoperative indications of coronary artery disease had at least one-vessel involvement and 29% had three-vessel, left main involvement. Resting (39 patients) and exercise multiple-gated acquisition scans (22 patients) did not predict the presence of coronary artery disease in patients without a history or electrocardiographic evidence of coronary artery disease. Myocardial revascularization was performed prior to aortic surgery in 17 patients (29%). The operative mortality was 3.7% with two patients dying from noncardiac-related complications. There were two additional deaths prior to aortic surgery with one patient dying during coronary artery bypass grafting, and one dying of aneurysm rupture prior to repair, making the overall mortality associated with this approach 7.4%. Preoperative cardiac catheterization and an aggressive approach toward coronary artery bypass grafting reduces the risk of cardiac complications in aortic surgery.     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

The risk of vascular surgery in a metropolitan community. With observations on surgeon experience and hospital size

From 1978 through 1981 complete perioperative information concerning a total of 10,189 peripheral vascular procedures performed in northeastern Ohio was recorded in the computer registry of The Cleveland Vascular Society. This report is an analysis of mortality and morbidity rates for all 5686 operations involving carotid endarterectomy (N = 2646), lower extremity revascularization (N = 1987), and abdominal aortic aneurysm resection (N = 1053). The operative mortality rate was 1.2% for carotid reconstruction, 2.8% for femoropopliteal or distal bypass, 3.5% for aortofemoral revascularization, and 11.9% for aortic aneurysm resection (elective operations 6.5%; emergency operations 32.9%). Postoperative strokes occurred after endarterectomy in 2.7% of patients having preoperative neurologic symptoms and in 2.0% of those with asymptomatic carotid stenosis. Lower extremity amputation was unavoidable in 1.5% of patients after aortofemoral reconstruction and in 6.0% after femoropopliteal or distal bypass. Statistical testing indicated that the operative mortality rate was not related to the respective size of the 27 hospitals involved in the survey. The relative annual experience of the 29 participating surgeons significantly influenced only the mortality rate of elective aneurysm resection and the amputation rate after femoropopliteal or distal revascularization. This study suggests that the results of major arterial reconstruction in metropolitan areas may be expected to be comparable to those of published series if the responsible surgeons are specifically trained and maintain an active interest in the field of vascular surgery.     

How to avoid cardiac ischemic events associated with aortic surgery.

Whereas there is some degree of coronary artery disease (CAD) in most patients undergoing vascular surgery, there is no consensus regarding how to avoid perioperative cardiac ischemic events. Although this edition of Seminars in Vascular Surgery is devoted to aortic surgery, it must be remembered that the incidence of adverse cardiac outcomes after infrainguinal operations is at least as great as after aortic procedures. Thus, much of the information discussed herein will be applicable to patients undergoing all varieties of vascular surgery. Numerous strategies exist for preoperative cardiac testing before vascular operations. These strategies range from routine evaluation before surgery to a "minimalist" approach, treating all patients as though CAD was present. Although advocates of various algorithms often are unwavering in their convictions, there are no randomized, prospective studies comparing different strategies for evaluation and management of patients with CAD undergoing vascular surgery. Potential adverse effects of evaluation and cardiac intervention should be considered before undertaking screening studies. The authors analyzed the adverse outcomes of preoperative cardiac evaluation and intervention before vascular operations in patients treated at the Denver Department of Veterans Affairs Medical Center. Of 153 patients undergoing vascular procedures, 42 had extended cardiac evaluations. Sixteen (38%) patients had untoward events related to this evaluation. Extensive cardiac evaluation before vascular operations can result in morbidity, delays, and refusal to undergo vascular surgery. The underlying indication for vascular operations and the local iatrogenic cardiac complication rates should be considered before ordering special studies. Several recent randomized, prospective studies have established that perioperative beta-adrenergic blockade is beneficial in vascular patients with CAD. Beta-Blocker therapy can reduce the risk of perioperative adverse cardiac outcomes by 55%. The Coronary Artery Revascularization Prophylaxis (CARP) trial currently underway is a multicenter, prospective comparison of invasive intervention for CAD versus best medical care in patients undergoing aortic and lower extremity vascular surgery funded by the Department of Veterans Affairs Cooperative Studies Program.     

Total arterial coronary revascularization and factors influencing in-hospital mortality.

OBJECTIVE: To determine if arterial conduit selection or more efficient arterial revascularization techniques influence in-hospital mortality. METHODS: Data from patients undergoing coronary artery bypass surgery at Royal Melbourne Hospital, Australia, between 1 January 1996 and 30 June 1998 (n = 1681) was collected prospectively. Logistic regression analysis was performed. RESULTS: Independent preoperative predictors of increased in-hospital mortality included renal failure, redo coronary artery surgery and intra-aortic balloon pump use. In-hospital mortality for total arterial revascularization 0.7%, radial artery use 0.9%, pedicled arterial revascularization 0.2%, composite arterial conduit 0.4%, and the exclusive Y graft operation 0.3%. These were all associated with reduced in-hospital mortality. Mortality when vein graft was used was 2.9%. Most patients received total arterial revascularization, which was considered the primary surgical strategy. CONCLUSION: Total arterial revascularization, radial artery use and complex arterial reconstructions were associated with reduced in-hospital mortality. Preoperative renal failure, intra-aortic balloon pump use and redo coronary surgery predicted greater in-hospital mortality.     

Patients with positive preoperative stress tests undergoing vascular surgery

OBJECTIVE: To examine the perioperative cardiac morbidity and mortality in patients undergoing major vascular surgery with beta-blockade after a positive stress test or cardiac catheterization. DESIGN: Retrospective review of a quality assurance database. SETTING: A university teaching hospital. PARTICIPANTS: A consecutive series of 31 patients undergoing peripheral vascular or aortic surgery after a positive stress test or catheterization between November 2001 and September 2003. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: All 31 patients had a preoperative positive stress test and/or cardiac catheterization, with 12 having multiple areas at risk for myocardial ischemia. None had an intervening coronary revascularization. Twenty-seven had at least one of the intermediate clinical predictors as defined by the American College of Cardiology and 7 had a left ventricular ejection fraction < 40%. Twenty-three patients had been on a beta-blocker and continued on it, while the remainder started on it de novo perioperatively. None of the patients suffered from myocardial infarction, congestive heart failure, or cardiac death perioperatively. CONCLUSIONS: This case series reports on the authors' experience with patients undergoing high-risk vascular surgery after a positive stress test or catheterization, but without an intervening coronary intervention. All patients received perioperative beta-blockade and had a very low adverse cardiac event rate. With reduction of adverse events by beta-blockade, the likelihood of a positive event may be reduced and the utility of the test in risk stratification may be questioned.