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.