Perioperative- and long-term mortality rates after major vascular surgery: the relationship to preoperative testing in the medicare population.

Debate continues regarding the value of cardiovascular testing and coronary revascularization before major vascular surgery. Whereas recent guidelines have advocated selective preoperative testing, several authors have suggested that it is no longer necessary in an era of low perioperative cardiac morbidity and mortality. We used data from a random sample of Medicare beneficiaries to determine the mortality rate after vascular surgery, based on the use of preoperative cardiac testing. A 5% nationally random sample of the aged Medicare population for the final 6 mo of 1991 and first 11 mo of 1992 was used to identify a cohort of patients who underwent elective infrainguinal or abdominal aortic reconstructive surgery. Use within the first 6 mo of 1991 was reviewed to determine if preoperative noninvasive cardiovascular imaging or coronary revascularization was performed. Thirty-day (perioperative) and 1-yr mortalities were assessed. Perioperative mortality was significantly increased for aortic surgery (209 of 2865 or 7.3%), compared with infrainguinal surgery (232 of 4030 or 5.8%); however, 1-yr mortality was significantly increased for infrainguinal surgery (16.3% vs 11.3%, P < 0.05). Stress testing, with or without coronary revascularization, was associated with improved short-and long-term survival in aortic surgery. The use of stress testing with coronary revascularization was not associated with reduced perioperative mortality after infrainguinal surgery. Stress testing alone was associated with reduced long-term mortality in patients undergoing infrainguinal revascularization. IMPLICATIONS: Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality. The reduced long-term mortality in patients who had previously undergone preoperative testing and coronary revascularization reinforces the need for a prospective evaluation of these practices.     

Preoperative cardiac risk assessment: an updated approach.

HYPOTHESIS: We provide an updated algorithm for approaching preoperative cardiac risk assessment in patients undergoing noncardiac surgery. DESIGN: A National Library of Medicine PubMed literature search was performed dating back to 1985 using the keywords "preoperative cardiac risk for noncardiac surgery." This search was restricted to English language articles involving human subjects. RESULTS: Patient-specific and operation-specific cardiac risk can be determined clinically. Patients with major cardiac risk factors have a high incidence of perioperative cardiac complications, whereas the risk is less than 3% for low-risk patients. For intermediate-risk patients, no prospective randomized studies demonstrate the efficacy of noninvasive stress testing (dipyridamole thallium or dobutamine echocardiography) or of subsequent coronary revascularization for preventing perioperative cardiac complications. Recent studies demonstrate that perioperative beta-blockade significantly reduces the adverse cardiac event rate in intermediate-risk patients. CONCLUSIONS: Most patients with high cardiac risk should proceed with coronary angiography. Patients with low cardiac risk can proceed to surgery without noninvasive testing. For intermediate-risk patients, consideration may be given to further stress testing prior to surgery; however, in most patients, proceeding to surgery with perioperative beta-blockade is an acceptable alternative.     

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.     

Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease

Electrocardiographically monitored arterial stress testing was performed before surgery in 130 patients with peripheral vascular disease. When limitations of claudication or pain at rest precluded treadmill exercise, arm ergometry was employed. The electrocardiographically monitored arterial stress test proved a cost-effective, easily applicable means of screening for coronary artery disease in this group of patients. Unlike statistical analyses of historical risk factors, the electrocardiographically monitored arterial stress test evaluates the current functional state of the myocardium. We believe that preoperative electrocardiographic exercise testing should be employed more widely and should be considered in any patient facing major surgery in whom coronary artery disease is suspected on the basis of past history or known risk factors. In patients who have an ischemic response to exercise, particularly at less than 75 percent of the maximum predicted heart rate, coronary angiography and possibly coronary revascularization should be considered before elective major surgery is performed.     

Risk-stratified screening for ischemic heart disease in kidney transplant candidates

BACKGROUND: Few studies have examined the effectiveness of a risk-stratified approach to screening kidney transplantation candidates for ischemic heart disease (IHD). METHODS: We retrospectively reviewed records from all adult patients (n = 514) placed on the deceased donor kidney transplantation waiting list at a single center between January 1992 and June 2000. During this time there was a consistent policy for high-risk patients to undergo noninvasive stress testing and/or coronary angiography. We examined screening tests, the resulting interventions, and the incidence of subsequent IHD events (myocardial infarction, angioplasty, bypass surgery, or IHD death) among those screened and not screened. RESULTS: For 224 (43.6%) low-risk patients who were not screened, the actuarial incidence of an IHD event after listing (before or after transplantation) was only 0.5% at 1 year, 3.5% at 3 years, and 5.3% at 5 years. Screening 290 (56.4%) high-risk patients resulted in prophylactic angioplasty in 18 (6.2%), and bypass surgery in 8 (2.8%) before listing. After listing, 61 patients were screened, resulting in angioplasty in 6 (9.8%) and bypass surgery in 1 (1.6%). Of the 68 patients who ultimately had an IHD event after being placed on the waiting list, only 13 (19.4%) had not been screened. CONCLUSIONS: A risk-stratified screening strategy effectively avoided unnecessary testing in 43.6%. However, the relatively low proportion of screened patients who underwent prophylactic angioplasty or bypass grafting raises the question of whether screening was effective in preventing IHD events.     

Cost of routine screening for carotid and lower extremity occlusive disease in patients with abdominal aortic aneurysms

OBJECTIVE: The burden of clinically relevant noncoronary atherosclerotic occlusive disease in patients with abdominal aortic aneurysms (AAAs) is poorly defined. Furthermore, the cost-effectiveness of routine versus selective preoperative noninvasive examination of the carotid and lower extremity arterial beds has not been established in patients who undergo elective AAA repair. METHODS: Diagnostic vascular laboratory study results were reviewed in 206 patients who underwent evaluation before AAA repair from 1994 to 1998. The patients underwent routine preoperative carotid duplex scan examinations and lower extremity Doppler scan arterial studies with ankle-brachial index (ABI) determinations. The medical records were reviewed for the identification of clinical evidence consistent with cerebrovascular or lower extremity arterial occlusive disease. The costs of routine screening and selective screening were determined with Medicare reimbursement schedules. RESULTS: The prevalence rate of advanced (80% to 100%) carotid artery stenosis (CAS) was 3.4%, and 18% of the patients had CAS between 60% and 100%. Advanced peripheral vascular occlusive disease (PVOD; ABI, <0.3) was found in 3% of the patients, and 12% of the patients had an ABI of less than 0.6. Most patients with advanced CAS (71%) or advanced PVOD (83%) had clinical indications of their disease. The absence of clinical evidence of disease had a negative predictive value of 99% for both advanced CAS and PVOD. The cost of routine screening for all patients for advanced CAS was $5445 per case. Routine screening for severe PVOD costs were $3732 per case discovered. In contrast, the costs for selective screening for advanced CAS or PVOD in patients with appropriate history or symptoms were $1258 and $785 per case found, respectively. CONCLUSION: Routine noninvasive diagnostic testing for the identification of asymptomatic CAS and PVOD in patients with AAA may not be justified. Preoperative screening is more clearly indicated for patients with AAAs who have clinical evidence suggestive of CAS or PVOD.     

Perioperaive evaluation and management in vascular surgery especially for arteriosclerosis obliterans

Perioperative cardiac event is relatively high in vascular surgery for arteriosclerosis obliterans (ASO), which is a major cause of postoperative death. ACC/AHA guideline and revised cardiac risk index (CRI) were advocated to assess risk factor stratification and to manage risk reduction. ACC/AHA guideline categorized all vascular procedures except carotid endarterectomy as high risk. Because almost all patients with ASO were aged and/or inactive, noninvasive testing was necessary in almost all patients by the stepwise bayesian strategy. Patients with revised CRI less than 1 point dominated about three fourths of all patients, whose prevalence and incidence of ischemic heart disease (IHD) were 2.5% and 1.3%, respectively. It seemed appropriate to apply noninvasive testing only for patients with revised CRI more than 2 points, and high risk indicated coronary angiography. Electrocardigrams obtained at baseline, immediately, and on the first 2 days after surgery appear to be cost-effective to diagnose IHD. Use of cardiac biomarkers was reserved for patients at high risk and those with clinical, or ECG evidence of myocardial infarction (MI). Beta-blockers or alpha-agonists were effective to reduce incidence of perioperative IHD. Although even optimal preoperative assessment and perioperative management, some patients will have perioperative MI.     

Validation of an updated approach to preoperative cardiac risk assessment in vascular surgery

To validate a more selective approach to cardiac assessment which consisted of limiting stress testing and coronary revascularization to highly selected patients and limiting coronary revascularization to patients with severe cardiac symptoms, we compared two time periods (1994-1995 and 2000-2001) with respect to cardiac work-up and cardiac morbidity and mortality. Our method involved a retrospective review of patients undergoing vascular procedures from 2000 to 2001 at a single institution. In group 1 (2000-2001), 139 operations were performed on 120 patients. In group 2 (1994-1995), 145 procedures were performed on 109 patients. Preoperative stress testing was reduced from 42 patients (29%) in group 2 to 20 patients (14%) in group 1 (P < 0.01), and preoperative coronary artery bypass grafting was reduced from six (4.1%) to two (1.4%) (P < 0.28), respectively. Coronary angiography was unchanged: 8 (5.8%) patients in group 1 versus 11 (7.9%) patients in group 2 (P = NS). Two (1.4%) patients underwent percutaneous transluminal coronary angioplasty in group 1 and group 2. Cardiac event rates were similar: seven (5%) patients in both groups. Cardiac death was not significantly different: two (1.4%) in group 1 versus one (0.7%) in group 2. Cardiac morbidity and mortality after major vascular surgery remain the same despite using a more selective cardiac stress protocol.     

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.     

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.     

Preoperative dipyridamole-thallium scanning, selective coronary revascularization and long-term survival in patients with critical lower limb ischemia

BACKGROUND: A large proportion of patients with critical limb ischemia have advanced, often asymptomatic coronary artery disease which is associated with increased perioperative risk and decreased long-term survival. METHODS: We evaluated retrospectively the short and long-term effect of routine dipyridamole-thallium cardiac scanning (DTS) and selective coronary revascularization in 113 consecutive patients who were scheduled for revascularization of the lower extremity. RESULTS: DTS was abnormal in 60 (53.1%) patients and demonstrated a moderate-severe reversible defect in 26 (23.0%) patients. On the basis of DTS and clinical evaluation 33 (29.2%) patients were referred for coronary catheterization. Of these, 9 underwent PTCA and 4 underwent coronary artery bypass, without complications. Surgical revascularization of the limbs was performed in all but two patients. Two (1.8%) patients died postoperatively, three (2.7%) sustained nonfatal postoperative myocardial infarctions. None of the patients who underwent preoperative coronary revascularization suffered a cardiac complication after the peripheral vascular operation. During mean follow-up of 31.7 months, 30 (28.0%) patients died. A moderate-severe reversible defect on DTS was the strongest predictor for shortened survival (Exp(b)=0.61, CI 95%=0.42-0.88; p=0.006). Patients who underwent preoperative coronary revascularization followed a survival curve approaching those without a reversible defect on DTS (mean survival 61+/-8 vs 63+/-4 months; NS) which was significantly better than those with such a defect who did not undergo coronary revascularization (mean survival 34+/-5 months; p=0.03). CONCLUSIONS: While the perioperative benefits of routine preoperative DTS screening in patients with critical limb ischemia, remain debatable, it provides an opportunity for identification and treatment of life-limiting coronary artery disease and improving survival.     

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.     

The evolving role of preoperative testing in vascular surgery patients: can a little knowledge be dangerous?

It has been traditionally recommended that candidates for vascular surgery receive noninvasive stress perfusion testing risk stratification to help decide which patients may benefit from coronary artery revascularization. Recent clinical trials have contested the efficacy of revascularization in this population as well as the information yield of noninvasive testing. This article reviews a number of these studies that are likely to change our beliefs regarding testing and subsequent interventions as well as evolving role of medical therapy in patients undergoing vascular surgery.     

Clinical experience with preoperative coronary angiography

CAD is the leading cause of postoperative and late death following peripheral vascular reconstruction. In an attempt to reduce the eventual incidence of fatal myocardial infarction, preoperative coronary angiography was obtained in a series of 1000 patients under serious consideration for elective vascular procedures at The Cleveland Clinic. Those patients found to have severe, surgically correctable CAD were advised to undergo myocardial revascularization as a combined or preliminary operation. Severe, correctable CAD was discovered in 25% of the study group, including 34% of patients suspected to have CAD by conventional clinical criteria in comparison to only 14% of those who were not (p = 2.0 X 10(-13) ). Although severe CAD also was more common among men, patients more than 60 years of age, and diabetic patients, the clinical cardiac status was the most reliable indication of the yield of coronary angiography. Coronary artery bypass was performed in 216 patients, and the operative mortality rate for 1292 cardiac and vascular procedures was 2.6%. On the basis of this experience, an algorithm was constructed to select peripheral vascular patients for noninvasive cardiac screening or coronary angiography.     

Preoperative coronary revascularization in high-risk patients undergoing vascular surgery: a core review

Patients undergoing vascular surgery are at increased risk for cardiac complications related to the presence of underlying coronary artery disease. Preoperative cardiac evaluation may help to identify high-risk patients in whom coronary angiography may be planned with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, the indications and efficacy for type of revascularization for the reduction of cardiac complications compared to medical therapy has been controversial. My aim in this review is to summarize the role of preoperative revascularization compared to conservative medical therapy before elective vascular surgery using current evidence from published studies.     

An assessment of the positive predictive value and cost-effectiveness of dipyridamole myocardial scintigraphy in patients undergoing vascular surgery

Purpose: The approach to cardiac risk stratification of patients undergoing vascular surgery continues to be controversial. The success of algorithms that use clinical risk factors to determine cardiac risk have been inconsistent. Dipyridamole myocardial scintigraphy (DMS) has been accepted as a sensitive, noninvasive approach to risk stratification with excellent negative predictive value. Low positive predictive value (PPV) of abnormal DMS scans is a shortcoming that contributes to extensive preoperative cardiac evaluation and intervention with associated morbidity, mortality, and cost in most patients who undergo uncomplicated vascular procedures, regardless of DMS results.Methods: Over 6 years, 237 patients underwent DMS before surgical management of infrarenal aortic aneurysm, aortoiliac, or infrainguinal occlusive disease. The value of multiple clinical factors and DMS were assessed retrospectively for the prediction of perioperative myocardial infarction (MI), heart-related death, or preoperative selection for myocardial revascularization. Only congestive heart failure and two or more reversible defects on DMS were statistically significant on logistic regression analysis.Results: The PPV of DMS was 19% for all patients with reversible defects, 12% for patients with one reversible defect, and 36.7% for patients with two or more reversible defects. The rates of cardiac death and MI were 1.3% and 5.9%, respectively. Perioperative echocardiography revealed unchanged postinfarction ejection fraction in most patients who experienced MI. Cost-effectiveness of DMS screening was evaluated.Conclusions: The costs per MI and cardiac death averted suggest a decline in cost-effectiveness of screening with DMS over time, assuming improving cardioprotective strategies of patient care. Clinical risk factors were minimally useful in the prediction of perioperative MI, heart-related death, or need for myocardial revascularization. The PPV of DMS is low, and the majority of MIs may be clinically insignificant. The cost-effectiveness of cardiac screening with DMS may not be justifiable given current trends of health care reform. (J VASC SURG 1994;19:112-24.)     

Detection of coronary artery disease in acute aortic dissection: the efficacy of 64-row multidetector computed tomography

We herein describe a case with an acute aortic dissection, whose atherosclerotic coronary artery disease (CAD) could be accurately detected using a preoperative 64-row multidetector computed tomography (MDCT). Emergency surgery including a coronary artery bypass grafting and a total arch replacement were successfully performed without causing perioperative myocardial infarction. MDCT coronary angiography is a safe and noninvasive examination, therefore, we believe that MDCT coronary angiography should become a routine preoperative examination for patients with an acute aortic dissection in order to detect the presence of CAD.     

高危患者在血管外科手术前行冠状动脉重建术之利弊综述

血管外科手术患者如合并有冠状动脉疾病,发生心血管并发症的风险将增加。手术前心血管功能评估有助于发现需要进行冠状动脉造影的高危患者,并随后进行冠状动脉重建术,以达到改善围手术期甚至长期心血管转归的目的。但与药物治疗相比,冠状动脉重建手术的适应证和减少心血管并发症的有效性仍存在争议。本文通过分析已发表的文献,探讨与保守的药物治疗相比,手术前行血管重建术在择期血管手术中的作用。