Coronary artery revascularization before major vascular surgery

Edward O. McFalls, Robert S. Schwartz

Research output: Contribution to journalArticlepeer-review

Abstract

Cardiac risk associated with major vascular surgery is very high, largely because of the high rate of comorbid coronary artery disease (CAD) in patients requiring vascular surgery. Patients in need of an elective operation for either an expanding aortic aneurysm or lower limb ischemia have the highest risk of post-operative cardiac complications due to the high prevalence of CAD in these patients as well as the hemodynamic stresses associated with the two vascular procedures. In the case of open aortic aneurysm repair, for example, peri-operative and long-term mortality rates are highest among patients who have symptomatic CAD (i.e., class III to IV angina pectoris or congestive heart failure), intermediate in those who have chronic stable angina and/ or a history of remote myocardial infarction (MI), and lowest among those who have no indication of coronary disease whatsoever. (For a look at the general risk of various types of noncardiac surgical procedures, see Slide 1.) Because the incidence of perioperative cardiac complications is high, experts have proposed a rigorous process of risk stratification, beginning with the original Goldman criteria from the 1970s through the recent revision of the Cardiac Risk Index by Lee and colleagues. Still, the optimal treatment of patients undergoing elective vascular surgery has been one of the most randomized patients did significantly worse than those who were excluded from the study due to their lower cardiac risks, suggesting that the screening process correctly identified high-risk patients. The investigators concluded that coronary artery revascularization before elective vascular surgery does not alter long-term survival or provide short-term benefits; however, this approach may delay the needed vascular surgery by 6-8 weeks or longer. The recent ACC/AHA guidelines on managing patients with peripheral artery disease noted that based on the evidence now available, specifically the CARP data, "the role of coronary artery revascularization in the context of contemporary medical management appears to be less than traditionally assumed".

Original languageEnglish (US)
Pages (from-to)25-29
Number of pages5
JournalACC Cardiosource Review Journal
Volume15
Issue number4
StatePublished - Apr 1 2006

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