Unexpected, Late Cardiovascular Effects of Surgery for Peripheral Artery Disease

Abstract

In reviewing late morbidity of a multicenter clinical trial comparing balloon angioplasty (percutaneous transluminal angioplasty) with bypass surgery for lower-extremity ischemia, an unexpectedly high incidence of adverse systemic events in surgical patients was uncovered. The study was prospective and randomized, and included a total of 263 patients, with follow-up from 2 to 6 years. When end points of related deaths, amputations, and intervention failures were summed, surgery was favored over percutaneous transluminal angioplasty at 4 years. Progression of cardiac and renal dysfunction and mortality differed between groups. A total of 42 deaths were in the group who underwent surgery and 27 in those who underwent percutaneous transluminal angioplasty. The percentage difference in death rate between the two groups increased each year to reach 10% at 5 years. A significant difference in renal function was noted in nine patients who underwent surgery and zero who underwent percutaneous transluminal angioplasty. Myocardial infarctions were greater on follow-up of surgical patients. After 6 years, congestive heart failure had occurred in 19 patients who underwent surgery and eight who underwent percutaneous transluminal angioplasty. The trends in this study of patients with only moderately severe peripheral arterial disease suggest an increased rate of deterioration of cardiac and renal function in patients who have arterial operations. In surgical patients, mortality was 13.1% per year, whereas it was 8.4% for patients treated with percutaneous transluminal angioplasty. Future intervention studies should include long-term follow-up of such cardiovascular events.

Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients

“…However, a multicenter prospective randomized study comparing percutaneous transluminal angioplasty with bypass surgery for lower extremity ischemia in the general population, the Veterans Affairs Cooperative Study 199, revealed considerably higher 5-year morbidity and mortality rates in patients undergoing surgical revascularization. In surgically treated patients, mortality was 13.1% per year, whereas it was 8.4% per year for patients treated with angioplasty [29].…”

Risk Factors for Long-Term Mortality and Amputation after Open and Endovascular Treatment of Acute Limb Ischemia

“…Prior studies suggest that major post-operative AEs portend a negative impact on later outcomes beyond the initial hospitalization. 6 ALI patients are at risk of a tumultuous post-operative course secondary to their poor medical optimization and the need for urgent revascularization, which is associated with longer and more complicated procedures with higher blood loss. 4-6,11,20 Certain subsets of ALI patients will likely have a greater benefit from one type of revascularization technique over another given the heterogeneity of ALI patients with variable etiologies, comorbidities, and physiologic reserve.…”

“…This subpopulation represents the most challenging of the ALI patients to treat given their advance disease and comorbidities placing them at the highest risk not only for postoperative complications, but limb loss and mortality beyond the initial perioperative period, with a 27% amputation rate and a 65% mortality rate at 5 years. 4-6,24 …”

“…5,12,13,20,25 While ER patients had a favorable AE profile, technical failure remains a significant disadvantage of this therapy, with previous reported rates of 20-50%, and 22% failure in our cohort. 6,11,12,14,15,20 …”

“…2-5 Older reports estimate 5-year mortality to be as high as 33-83%. 6-8 ALI patients are extremely heterogeneous with numerous comorbidities and limited physiologic reserve. Compared to patients treated electively for peripheral arterial disease, ALI patients are not medically optimized and present with advanced disease states contributing to significantly higher post-operative complications, mortality and limb loss.…”