Background: Coronary artery disease is the primary cause of death in patients with carotid artery disease and silent ischemia is a marker for adverse coronary events. A new noninvasive cardiac diagnostic test, coronary computed tomography-derived fractional flow reserve (FFR CT ) can reliably identify ischemia-producing coronary stenosis in patients with coronary artery disease and help to select patients for coronary revascularization. The purpose of this study is to determine the prevalence of silent coronary ischemia in patients undergoing carotid endarterectomy (CEA) and to evaluate the usefulness of FFR CT in selecting patients for coronary revascularization to decrease cardiac events and improve survival.Methods: Patients with no cardiac history or symptoms admitted for elective CEA were enrolled in a prospective, openlabel, institutional review board-approved study and underwent preoperative coronary computed tomography angiography (CTA) and FFR CT with results available to physicians for patient management. Lesion-specific coronary ischemia was defined as FFR CT of 0.80 or less distal to a focal coronary stenosis with an FFR CT of 0.75 or less, indicating severe ischemia. Primary end point was incidence of major adverse cardiovascular events (MACE; defined as cardiovascular death, myocardial infarction, or stroke) at 30 days and 1 year.Results: Coronary CTA and FFR CT was performed in 90 CEA patients (age 67 6 8 years; male 66%). Lesion-specific coronary ischemia was found in 51 patients (57%) with a mean FFR CT of 0.71 6 0.14. Severe coronary ischemia was present in 39 patients (43%), 26 patients had multivessel ischemia, and 5 had left main disease. CEA was performed as scheduled in all patients with no postoperative deaths or myocardial infarctions. There were no MACE events at 30 days. After recovery from surgery, 36 patients with significant lesion-specific ischemia underwent coronary angiography with coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting) in 30 patients (33%). Survival at 1 year was 100% and freedom from MACE was 98%.Conclusions: Patients undergoing CEA have a high prevalence of unsuspected (silent) coronary ischemia, which may place them at risk for coronary events. Preoperative diagnosis of silent ischemia using CTA and FFR CT can identify highrisk patients and help to guide patient management. Selective postoperative coronary revascularization of patients with significant ischemia may decrease the risk of cardiac events and improve survival, but longer follow-up is needed and prospective, controlled trials are indicated.

WHAT THIS PAPER ADDS This study shows that pre-operative evaluation of patients undergoing lower extremity surgical revascularisation using coronary computed tomography derived fractional flow reserve can identify high risk patients with silent coronary ischaemia. This information can facilitate a multidisciplinary team approach to improve patient outcome. Increased focus on peri-operative cardiac care combined with selective post-operative coronary revascularisation of patients with silent ischaemia resulted in fewer cardiovascular deaths and myocardial infarctions, and improved one year survival compared with patients having standard pre-operative cardiac evaluation. If confirmed by future studies, this strategy may improve long term survival of patients with peripheral vascular disease. Objective: Patients undergoing peripheral vascular surgery have increased risk of death and myocardial infarction (MI), which may be due to unsuspected (silent) coronary ischaemia. The aim was to determine whether preoperative diagnosis of silent ischaemia using coronary computed tomography (CT) derived fractional flow reserve (FFR CT) can facilitate multidisciplinary care to reduce post-operative death and MI, and improve survival. Methods: This was a single centre prospective study with historic controls. Patients with no cardiac symptoms undergoing lower extremity surgical revascularisation with pre-operative coronary CTA-FFR CT testing were compared with historic controls with standard pre-operative testing. Silent coronary ischaemia was defined as FFR CT 0.80 distal to coronary stenosis with FFR CT 0.75 indicating severe ischaemia. End points included cardiovascular (CV) death, MI, and all cause death through one year follow up. Results: There were no statistically significant differences between CT angiography (CTA-FFR CT) (n ¼ 135) and control (n ¼ 135) patients with regard to age (66 AE 8 years), sex, comorbidities, or surgery performed. Coronary CTA showed ! 50% stenosis in 70% of patients with left main stenosis in 7%. FFR CT revealed silent coronary ischaemia in 68% of patients with severe ischaemia in 53%. The status of coronary ischaemia was unknown in the controls. At 30 days, CV death and MI in the CTA-FFR CT group were not statistically significantly different from controls (0% vs. 3.7% [p ¼ .060] and 0.7% vs. 5.2% [p ¼ .066], respectively). Post-operative coronary revascularisation was performed in 54 patients to relieve silent ischaemia (percutaneous coronary intervention in 47, coronary artery bypass graft in seven). At one year, CTA-FFR CT patients had fewer CV deaths (0.7% vs. 5.9%; p ¼ .036) and MIs (2.2% vs. 8.1%; p ¼ .028) and improved survival (p ¼ .018) compared with controls. Conclusion: Pre-operative diagnosis of silent coronary ischaemia in patients undergoing lower extremity revascularisation surgery can facilitate multidisciplinary patient care with selective post-operative coronary revascularisation. This strategy reduced post-operative death and MI and improved one year survival compared with st...

Background: Patients with critical limb-threatening ischemia (CLTI) have had poor long-term survival after lower extremity revascularization owing to coexistent coronary artery disease. A new cardiac diagnostic test, coronary computed tomography-derived fractional flow reserve (FFR CT ), can identify patients with ischemia-producing coronary stenosis who might benefit from coronary revascularization. We sought to determine whether the diagnosis of silent coronary ischemia before limb salvage surgery with selective postoperative coronary revascularization can reduce the incidence of adverse cardiac events and improve the survival of patients with CLTI compared with standard care.Methods: Patients with CLTI and no cardiac history or symptoms who had undergone preoperative testing to detect silent coronary ischemia with selective postoperative coronary revascularization (group I) were compared with patients with standard preoperative cardiac clearance and no elective postoperative coronary revascularization (group II). Both groups received guideline-directed medical care. Lesion-specific coronary ischemia in group I was defined as FFR CT of #0.80 distal to a stenosis, with severe ischemia defined as FFR CT of #0.75. The endpoints included all-cause death, cardiovascular (CV) death, myocardial infarction (MI), major adverse CV events (i.MACE; CV death, MI, unplanned coronary revascularization, stroke) through 2 years of follow-up.Results: Groups I (n ¼ 111) and II (n ¼ 120) were similar in age (66 6 9 vs 66 6 7 years), gender (78% vs 83% men), comorbidities, and surgery performed. In group I, unsuspected, silent coronary ischemia was found in 71 of 103 patients (69%), with severe ischemia in 58% and left main coronary ischemia in 8%. Elective postoperative coronary revascularization was performed in 47 of 71 patients with silent ischemia (66%). In group II, the status of silent coronary ischemia was unknown. The median follow-up was >2 years for both groups. The 2-year outcomes for groups I and II were as follows: