Coronary-artery revascularization before elective major vascular surgery

McFalls, Edward O.; Ward, Herbert B.; Möritz, Thomas

doi:10.1016/j.accreview.2005.03.013

Cited by 235 publications

(339 citation statements)

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“…Furthermore, long-term outcomes of these patients in terms of death, cardiovascular death, cardiac event, and cardiovascular event were found to be equivalent to those of the AAA patients who did not have concomitant CAD. This result conformed with the results of a recent randomized trial carried out in patients undergoing major vascular surgery by McFalls et al 11 They failed to prove the benefits of the prophylactic treatment of CAD by PCI or CABG surgery. Percutaneous coronary intervention or CABG surgery was performed in AAA patients prior to surgical repair of AAA on the basis of the CAG findings, irrespective of the existence of myocardial ischemia; they failed to demonstrate its benefits on long-term outcomes.…”

Section: Discussionsupporting

confidence: 88%

“…1,9,10 Recently, however, a randomized trial carried out in patients undergoing major vascular surgery failed to demonstrate the benefits of prophylactic treatment with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery for the clinical outcomes in patients with angiographically determined coronary stenosis. 11 A controversy has arisen regarding the necessity of routine CAG and prophylactic invasive treatment for CAD prior to surgery for AAA.…”

Section: Introductionmentioning

confidence: 99%

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Management of Coronary Artery Disease in Patients Undergoing Elective Abdominal Aortic Aneurysm Open Repair

Hosokawa¹,

Takano²,

Aoki³

et al. 2008

Clinical Cardiology

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Background The efficacy of prophylactic coronary revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery in patients with abdominal aortic aneurysm (AAA) scheduled for open repair surgery remains controversial. Hypothesis Concomitant coronary artery disease (CAD) with no inducible ischemia can be medically treated in AAA patients undergoing open repair as long as the existence of CAD is recognized. Method A retrospective analysis of acute and long‐term outcomes was performed for 122 patients with AAA who underwent coronary arteriography (CAG) for preoperative evaluation followed by elective open repair. Results Preoperative CAG revealed no CAD in 54 patients (non‐CAD group) and the existence of CAD in 68 patients. Prophylactic PCI or CABG surgery was performed in 16 patients (CAD‐PCI/CABG group) with symptomatic angina, ischemia proven by pharmacological stress scintigraphy, or coexistence of reduced cardiac contraction and coronary stenosis in multiple vessels. Medical treatment was administered to 52 patients who had no signs of ischemia (CAD‐medical group). During the perioperative period, no cardiac event occurred irrespective of the existence of CAD. The long‐term outcomes in the CAD‐medical group were equivalent to those in the non‐CAD group. In the CAD‐PCI/CABG group, the cardiac event‐free rate was comparable with that of other groups, although mortality was higher. Conclusion In patients undergoing AAA open repair, medical treatment for concomitant CAD with no obvious inducible ischemia does not confer unfavorable outcomes. Although prophylactic coronary revascularization possibly prevents future cardiac events, it appears to be necessary in a very limited number of cases. Copyright © 2008 Wiley Periodicals, Inc.

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Section: Discussionsupporting

confidence: 88%

Section: Introductionmentioning

confidence: 99%

Management of Coronary Artery Disease in Patients Undergoing Elective Abdominal Aortic Aneurysm Open Repair

Hosokawa¹,

Takano²,

Aoki³

et al. 2008

Clinical Cardiology

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“…Because it is impossible to predict when acute coronary plaque rupture will occur, studying perturbations underlying the transition from stable to unstable plaque is unfeasible in an outpatient setting. There is a predictable rate of perioperative myocardial infarction after surgery (up to 20-25% after noncardiac vascular surgery [3], for instance), and in a relatively controlled environment, patients can be profiled in both clinical and molecular detail before and after surgical stress to dissect pathways involved in the pathogenesis of thrombosis. A similar paradigm would operate for other cardiovascular disorders, such as cardiac arrhythmias and cerebrovascular events.…”

Section: Importance Of the Perioperative Periodmentioning

confidence: 99%

Understanding the Transition to Acute Illness: The Promise of Perioperative Genomics

Turer

Schwinn

2008

J. of Cardiovasc. Trans. Res.

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Over the last decades, tremendous advances have been made in understanding the genomic basis of a large number of chronic human diseases. Such advances were made possible by studying large numbers of patients over relatively long periods of time. It is increasingly recognized that acute robust stress stimulates pathways activated in chronic disease, facilitating mechanistic studies in much shorter time frames. A new field of molecular medicine, called perioperative genomics, uses robust surgical stress as a perturbation designed to explore such mechanisms. This new field is described briefly below. KeywordsPerioperative Care; Genomics; Risk Assessment; Postoperative Complications; Acute Disease Importance of the Perioperative PeriodMore than 40 million patients undergo surgery in the United States each year, and that number is expected to rise by 25% by 2020 [1]. In terms of monetary costs, the numbers are staggering with current estimates of $450 billion spent annually in the perioperative period [2]. Adverse events such as perioperative myocardial injury, renal failure, cognitive dysfunction, and stroke are devastating. Cardiovascular complications can occur after procedures even in patients without known heart disease. This problem is increasing as the population ages and cardiac risk factors, such as hypertension and diabetes mellitus, become more prevalent.Outside of its overall economic impact, the perioperative period provides an ideal model of acute illness. Although a dynamic and complicated environment, the operating room offers unique advantages for studying patients. In this environment, physiologic changes from baseline with robust stress can be prospectively quantified (e.g., hemo-dynamic parameters or plasma biomarkers). Even perturbations such as drug administration and organ ischemic time can be studied. Exposure to extremes of physiology offers the advantage of revealing (uncovering) phenotypes which might otherwise be dormant or take years to be expressed. Indeed, for patients at risk for proinflammatory activation, the operating room may transition an otherwise healthy individual into one who is acutely ill and at risk for postoperative complications and organ dysfunction.Coronary thrombosis is one example of how perioperative genomics can aid our understanding of illness beyond the operating room. There are more than one million spontaneous myocardial infarctions annually in the United States, but despite this incidence, molecular events triggering

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“…12 At the moment, however, there is no strong data to support prophylactic surgical or endovascular myocardial revascularization in reducing perioperative cardiac risk after major vascular surgery. 13 Godet et al 14 demonstrated that preoperative coronary intervention does not seem to significantly reduce the risk of cardiac complications in the perioperative period in patients undergoing aortic surgery. The recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines 9 stated that myocardial intervention is rarely necessary to simply lower the risk of vascular surgery unless such intervention is indicated, regardless of the patients' preoperative status.…”

Section: Introductionmentioning

confidence: 99%

Preoperative Cardiac Assessment in Patients Undergoing Aortic Surgery: Analysis of Factors Affecting the Cardiac Outcomes

Troisi

Dorigo

Sapio

et al. 2010

Annals of Vascular Surgery

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Background: The purpose of this study was to evaluate the effectiveness of a standardized preoperative cardiac assessment in reducing the rate of perioperative cardiac complications in patients undergoing aortic surgery, paying particular attention to the analysis of the factors affecting perioperative cardiac outcomes. Methods: Between January 2005 and August 2008, a total of 531 elective interventions for abdominal aortic aneurysms were performed at our institution. All patients underwent preoperative evaluation on an outpatient basis, which included a standardized cardiac assessment protocol to evaluate perioperative cardiac risk. A surgical (open or endovascular) intervention was performed in all patients and perioperative (<30 days) results in terms of overall and cardiac mortality and morbidity rates were recorded. Results: Preoperative electrocardiogram, transthoracic echocardiography, and cardiology consultation were performed in all patients. In 348 cases (65.5%), further evaluation of cardiac functional capacity with noninvasive stress testing was recommended. A positive noninvasive stress test was noted in 86 (24.7%) of 348 patients and coronary angiography was performed in 34 (39.5%) of 86 patients. Thirteen of these patients underwent successful coronary revascularization (11 percutaneous transluminal coronary angioplasty, two coronary artery bypass graft) before vascular surgery. Thirty-day overall rate and cardiac mortality rate were 1.1% and 0.6%, respectively, and 30-day overall and cardiac morbidity rates were 11.5% and 6.8%, respectively. Univariate analysis demonstrated that in patients aged >80 years, chronic renal failure, congestive heart failure, valvular heart disease, positive noninvasive stress testing, and open surgical treatment significantly affected 30-day cardiac morbidity; however, only valvular heart disease and positive noninvasive stress testing maintained their significance with multivariate analysis ( p ¼ 0.005; 95% CI, 1.6-14.4; and p ¼ 0.02; 95% CI, 1.2-8

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Coronary-artery revascularization before elective major vascular surgery

Cited by 235 publications

References 0 publications

Management of Coronary Artery Disease in Patients Undergoing Elective Abdominal Aortic Aneurysm Open Repair

Management of Coronary Artery Disease in Patients Undergoing Elective Abdominal Aortic Aneurysm Open Repair

Understanding the Transition to Acute Illness: The Promise of Perioperative Genomics

Preoperative Cardiac Assessment in Patients Undergoing Aortic Surgery: Analysis of Factors Affecting the Cardiac Outcomes

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