A Comparison of Distal End-to-side and End-to-end Anastomoses in Femoropopliteal Bypasses

OBJECTIVES

to compare end-to-side (ETS) and end-to-end (ETE) distal anastomoses. Design retrospective cohort study.

METHODS

retrospective cohort study. Between 1988 and 1992, 204 femoropopliteal bypasses (188 patients) were performed for claudication (55%), rest pain (22%) and tissue loss (23%). One hundred and eighteen ETS were compared with 86 ETE in terms of patency or a mean (range) follow-up of 68 (0.5-120) months.

RESULTS

overall patency was 86%, 66% and 57% at 1, 5 and 8 years, respectively. Multivariate analysis showed ETE anastomoses (p =0.04), and also knee bypass ( p =0.05) and venous conduit ( p =0.004) to be significantly associated with impaired patency.

CONCLUSIONS

ETE may improve femoropopliteal bypass patency.

Endovascular repair of an extracranial internal carotid artery aneurysm complicated by heparin-induced thrombocytopenia and thrombosis

PURPOSE

To report the endovascular treatment of a symptomatic extracranial internal carotid artery (ICA) aneurysm that was complicated by heparin-induced thrombocytopenia and thrombosis.

METHODS AND RESULTS

After undergoing a coronary artery bypass graft procedure, a patient was diagnosed with a symptomatic, 3.5-cm ICA aneurysm by computed tomography and angiography. Via a semiclosed access, an Enduring vascular graft was inserted under controlled back bleeding from the ICA. The patient was recovering uneventfully when routine duplex scanning on the fifth postoperative day suggested multiple thrombi within the graft, which was confirmed by arteriography. Thrombectomy and local fibrinolysis were performed; however, the graft occluded the next day without causing neurological symptoms. Heparin-induced thrombocytopenia was diagnosed by enzyme-linked immunosorbent assay.

CONCLUSIONS

Endovascular repair of high cervical extracranial ICA aneurysms is feasible, and protection against intracerebral embolization can be achieved using a semiclosed technique with controlled back bleeding from the ICA during endograft deployment. However, multiple thrombi or thrombotic occlusion during the postoperative period, particularly in a patient already sensitized to heparin, should direct attention toward possible heparin-induced thrombocytopenia.

Vascular response in the femoropopliteal segment after implantation of an ePTFE balloon-expandable endovascular graft: an intravascular ultrasound study

PURPOSE

To use intravascular ultrasound (IVUS) to document changes in vascular dimensions after placement of a balloon-expandable endograft.

METHODS

Thirteen patients (9 men; mean age 62 years, range 47-75) treated with an investigational polytetrafluoroethylene endograft for obstructive disease of the femoropopliteal segment were studied with IVUS immediately after endograft implantation and at follow-up. Corresponding IVUS cross sections were analyzed for changes in lumen, vessel, and plaque areas seen inside the endograft, in the anastomotic segment, and in the remote arterial segment.

RESULTS

A mean 6-month (range 1.5-9) follow-up was completed in 12 patients. Matched IVUS cross sections derived from within the endograft (n = 12) and at the endograft edges (n = 23) showed no change in lumen area (LA) in 17, reduction in 11, and dilatation in 7. Median changes within the endograft (+3%) were not significant (p = 0.28) and no neointima was found. Cross sections obtained at the anastomotic segment revealed a significant increase in LA (85%, p < 0.001), which was associated with a significant increase in both vessel area (VA) (42%, p < 0.001) and plaque area (PLA) (15%, p = 0.003) area. In the remote arterial segment, the change in LA was minimal (6%, p = 0.07), as were changes in the VA (9%, p = 0.04) and PLA (10%, p = 0.07).

CONCLUSIONS

Following endograft placement, luminal changes within the endograft, at the endograft edges, and at the remote arterial segments were minimal. Intimal hyperplasia was not observed in the endograft. The distinct LA increase at the anastomotic segments was determined by the extent of VA and PLA change.

Harmonization of vascular surgical training in Europe. A task for the European Board of Vascular Surgery (EBVS)

The competence of vascular surgeons defined as the level of skill, knowledge and experience necessary to safely perform vascular surgical procedures is determined to a high degree by the quality of the preceding training. In Europe, quality assurance of vascular surgical training, unlike in the USA, is not uniform and is not the responsibility of a centralized European authority, but is a matter in which the different countries have autonomous regulations. Consequently, different targets for duration, contents and general principles for training in vascular surgery have been set. Although in the past this may not have been a problem, the unification of countries in the European Community (EC), at present known as the European Union (EU), has changed this perspective because there is increasing impetus towards a mutual recognition of trade and education between member states. In 1975, EC directive 75/362 was adopted, which insured 'freedom of migration' for medical doctors along with many other professional trades (Publications of the European Communities no. L167, 30-6-1975, p. 1). This directive implicated that certificates, diplomas and other documents issued by the national competent authorities proving medical qualification allowed physicians to practice in any EU country. In order to make this law practical it seems essential that specialist training programmes throughout the EU should conform to certain agreed basic standards. The objective of this article is to present an overview on the current pattern of vascular surgical training in Europe. In addition, the structures that were established during the recent years to promote uniformly high standards of training in vascular surgery throughout the EU will be discussed.

Role of dobutamine stress echocardiography for preoperative cardiac risk assessment before major vascular surgery: a diagnostic tool comes of age

BACKGROUND

Cardiac complications are a major cause for perioperative mortality and morbidity. Also, the presence and severity of underlying coronary artery disease (CAD) determine long-term prognosis after successful surgery.

AIM

This overview evaluates the additional value of dobutamine stress echocardiography (DSE) to common clinical cardiac risk factors and other noninvasive cardiac imaging modalities for perioperative and late cardiac prognosis.

RESULTS

DSE provides theattending physician with preoperative prognostic information for perioperative and long-term prognosis for cardiac events. It also enables the selection of high risk patients for evaluation of cardiac risk reduction therapies.

CONCLUSIONS

DSE is a useful tool for preoperative cardiac risk evaluation in addition to common clinical cardiac risk factors.

The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

BACKGROUND

Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery.

METHODS

We performed a randomized, multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events. High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography. Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol.

RESULTS

A total of 1351 patients were screened, and 846 were found to have one or more cardiac risk factors. Of these 846 patients, 173 had positive results on dobutamine echocardiography. Fifty-nine patients were randomly assigned to receive bisoprolol, and 53 to receive standard care. Fifty-three patients were excluded from randomization because they were already taking a beta-blocker, and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing. Two patients in the bisoprolol group died of cardiac causes (3.4 percent), as compared with nine patients in the standard-care group (17 percent, P=0.02). Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (P<0.001). Thus, the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (3.4 percent) and 18 patients in the standard-care group (34 percent, P<0.001).

CONCLUSIONS

Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery.

Selecting subjects for ultrasonographic screening for aneurysms of the abdominal aorta: four different strategies

BACKGROUND

We studied whether the effectiveness of ultrasound screening for abdominal aortic aneurysms could be increased by preselecting high-risk subjects, based on the presence of risk indicators for the disease.

METHODS

In a population-based screening programme for abdominal aortic aneurysms among 5328 subjects living in Rotterdam, The Netherlands, we studied four different strategies to select subjects for ultrasound screening of the abdominal aorta, based on risk indicators for abdominal aortic aneurysm disease. Risk indicators used in each strategy were entered in a logistic regression model to predict the probability of an individual having an abdominal aortic aneurysm. Using several cutoff values for the probability of a subject having an aneurysm for each strategy, we estimated the proportion of subjects that should be referred for ultrasound screening and the proportion of aneurysms that would be diagnosed by each strategy (sensitivity).

RESULTS

When a probability of 1.5% of having an aneurysm is chosen as the cutoff point above which ultrasound screening is indicated, the proportion of subjects that would be referred for screening ranged from 36% (first strategy) to approximately 50% (other strategies), while 80% (first strategy) to approximately 94% (other three strategies) of all aneurysms would be detected.

CONCLUSION

Effectiveness in screening for abdominal aortic aneurysms can be increased by selecting subjects by means of a short medical questionnaire, filled out by the screening candidates, including questions on medical history.

Endovascular stent-grafts for aneurysms of the femoral and popliteal arteries

Our objective was to investigate the preliminary use of endovascular stent-grafts for the treatment of femoropopliteal artery aneurysm. Ten patients with an aneurysm of the femoropopliteal artery referred for endovascular treatment were investigated. The series consisted of patients with a true aneurysm of the superficial femoral artery (n = 2); a true aneurysm of the popliteal artery (n = 4); an aneurysmal dilatation of a Biograft bypass (n = 2); a false aneurysm of the superficial femoral aneurysm (n = 1); and a false aneurysm of a composite bypass (n = 1). In 8 of the 10 patients the stent-graft was composed of one or more Palmaz stents sutured to an ePTFE tube graft; in the other 2 patients a venous covering was used in combination with Palmaz stents. The procedure was guided by angiography and intravascular ultrasound. The results of our investigation showed that endovascular stent-grafting of aneurysms of the femoropopliteal artery is a feasible but experimental technique that should be restricted to a selected group of patients.

Is organ ischaemia a determinant of the outcome of operations for suprarenal aortic aneurysms?

OBJECTIVE

To find out if morbidity and mortality after thoracoabdominal approaches for suprarenal aortic aneurysms are related to the duration of organ ischaemia.

DESIGN

Retrospective study.

SETTING

University hospital, The Netherlands.

SUBJECTS

72 operations for suprarenal aortic aneurysms.

MAIN OUTCOME MEASURES

Duration of organ ischaemia, morbidity and mortality.

RESULTS

There were 72 patients with 3 group A (Crawford type III), 10 group B (Crawford type IV), 37 group C (supracoeliac), and 22 group D (suprarenal) aneurysms. Median duration of ischaemia was 57 minutes for both the spinal cord and the mesenteric arteries, and 59 and 63 minutes for the right and left renal arteries, respectively. There were 52 major complications in 33 patients. Mesenteric ischaemia of longer than 60 minutes was associated with a significant higher complication rate (21/32, 66% compared with 13/40, 33%, p = 0.01). Spinal cord ischaemia of longer than 60 minutes was not associated with a significantly increased incidence of paraplegia (2/40 compared with 6/32, p = 0.13).

CONCLUSIONS

We conclude that with surgery for suprarenal aneurysms a significant higher complication rate is noted with increased duration of mesenteric ischaemia.

Accurate assessment of abdominal aortic aneurysm with intravascular ultrasound scanning: validation with computed tomographic angiography

PURPOSE

The purpose of this study was to assess the accuracy of intravascular ultrasound (IVUS) parameters of abdominal aortic aneurysm, used for endovascular grafting, in comparison with computed tomographic angiography (CTA).

METHODS

This study was designed as a descriptive study. Between March 1997 and March 1998, 16 patients with abdominal aortic aneurysms were studied with angiography, IVUS (12.5 MHz), and CTA. The length of the aneurysm and the length and lumen diameter of the proximal and distal neck obtained with IVUS were compared with the data obtained with CTA. The measurements with IVUS were repeated by a second observer to assess the reproducibility. Tomographic IVUS images were reconstructed into a longitudinal format.

RESULTS

IVUS results identified 31 of 32 renal arteries and four of five accessory renal arteries. A comparison of the length measurements of the aneurysm and the proximal and distal neck obtained with IVUS and CTA revealed a correlation of 0.99 (P <.001), with a coefficient of variation of 9%. IVUS results tended to underestimate the length as compared with the CTA results (0.48 +/- 0.52 cm; P <.001). A comparison of the lumen diameter measurements of the proximal and distal neck derived from IVUS and CTA showed a correlation of 0.93 (P <.001), with a coefficient of variation of 9%. IVUS results tended to underestimate aneurysm neck diameter as compared with CTA results (0.68 +/- 1.76 mm; P =.006). Interobserver agreement of IVUS length and diameter measurements showed a good correlation (r = 1.0; P <.001), with coefficients of variation of 3% and 2%, respectively, and no significant differences (0.0 +/- 0.16 cm and 0.06 +/- 0.36 mm, respectively). The longitudinal IVUS images displayed the important vascular structures and improved the spatial insight in aneurysmal anatomy.

CONCLUSION

Intravascular ultrasound scanning results provided accurate and reproducible measurements of abdominal aortic aneurysm. The longitudinal reconstruction of IVUS images provided additional knowledge on the anatomy of the aneurysm and its proximal and distal neck.

Spinal-cord stimulation in critical limb ischaemia: a randomised trial. ESES Study Group

BACKGROUND

For patients with critical limb ischaemia, spinal-cord stimulation has been advocated for the treatment of ischaemic pain and the prevention of amputation. We compared the efficacy of the addition of spinal-cord stimulation to best medical treatment in a randomised controlled trial.

METHODS

120 patients with critical limb ischaemia not suitable for vascular reconstruction were randomly assigned either spinal-cord stimulation in addition to best medical treatment or best medical treatment alone. Primary outcomes were mortality and amputation. The primary endpoint was limb survival at 2 years.

FINDINGS

The mean (SD) age of the patients was 72.6 years (10.3). Median (IQR) follow-up was 605 days (244-1171). 40 (67%) of 60 patients in the spinal-cord-stimulator group and 41 (68%) of 60 patients in the standard group were alive at the end of the study, (p=0.96). There were 25 major amputations in the spinal-cord-stimulator group and 29 in the standard group, (p=0.47). The hazard ratio for survival at 2 years without major amputation in the spinal-cord stimulation group compared with the standard group was 0.96 (95% CI 0.61-1.51).

INTERPRETATION

Spinal-cord-stimulation in addition to best medical care does not prevent amputation in patients with critical limb ischaemia.

Intravascular ultrasound in endovascular stent-grafts for peripheral aneurysm: a clinical study

PURPOSE

To evaluate the potential diagnostic information of intraprocedural intravascular ultrasound (IVUS) in patients undergoing endovascular stent-grafting for peripheral aneurysm.

METHODS

IVUS was used in 17 patients preprocedurally to measure the diameter of the proximal and distal neck and the length of the aneurysm. Balloon and stent-graft sizes were selected based on these measurements. Following stent-graft deployment, angiography and IVUS were used to document stent apposition and the configuration and diameter of the stent-graft.

RESULTS

Stent-graft insertion was considered successful in 8 patients based on angiography and IVUS images. In 9 others, both imaging modalities showed inadequate results, necessitating 12 additional procedures: balloon angioplasty for stent-graft stenosis (2) and inadequate stent-graft apposition (1); an additional stent-graft (4); an extra stent (1); thrombectomy (2); and conversion (2) for inadequate stent-graft position and a graft rupture. In these patients, intraprocedural IVUS was superiorto angiography in contributing vital information to aid in the selection of the additional interventions.

CONCLUSIONS

During management of peripheral aneurysms with endovascular stent-grafts, IVUS monitoring was a useful adjunct when the initial procedure was unsatisfactory and/ or when intraprocedural angiographic studies were inconclusive.

Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: a randomized trial

PURPOSE

Subfascial division of incompetent perforating veins plays an important role in the surgical treatment of patients with venous ulceration of the lower leg. To minimize the high incidence of postoperative wound complications after open exploration, endoscopic approaches have recently been developed. We carried out a prospective, randomized comparison of open and endoscopic treatment of these patients that was aimed at ulcer healing and postoperative wound complications.

METHODS

Patients with current venous ulceration on the medial side of the lower leg were randomly allocated to open exploration by the modified Linton approach or endoscopic exploration by use of a mediastinoscope.

RESULTS

Thirty-nine patients were randomized, 19 to open exploration and 20 to endoscopic exploration. The incidence of wound infections after open exploration was 53%, compared with 0% in the endoscopic group (p < 0.001). Patients in the open group needed longer hospital stays (mean, 7 days; range, 3 to 39 days) than patients in the endoscopic group (mean, 4 days; range, 2 to 6 days; p = 0.001). Four months after operation, the ulcers of 17 patients (90%) in the open group and 17 patients (85%) in the endoscopic group had healed. During a mean follow-up of 21 months (range, 16 to 29 months), no recurrences were noticed in either group.

CONCLUSIONS

Endoscopic division of incompetent perforating veins is equally as effective as open surgical exploration for the treatment of venous ulceration of the lower leg but leads to significantly fewer wound healing complications. Endoscopic division is therefore the preferred method.

Efficacy of subfascial endoscopy in eradicating perforating veins of the lower leg and its relation with venous ulcer healing

PURPOSE

The purpose of this study was to investigate the efficacy of subfascial endoscopy by use of a mediastinoscope in the identification and ligation of incompetent perforating veins in patients with venous ulceration of the lower leg.

METHODS

All patients who underwent subfascial endoscopy for venous ulceration between Jan. 1, 1994, and Mar. 1, 1995, at the Sint Franciscus Gasthuis in Rotterdam underwent duplex ultrasound scans of the lower leg before and 6 weeks after operation. The number and localization of the perforating veins on the mediodorsal side were compared with the findings during subfascial endoscopy.

RESULTS

In 20 patients, preoperative duplex examination showed 46 incompetent and six competent perforating veins. During operation the site of 43 incompetent and all competent perforating veins was confirmed. Five additional perforating veins were found at operation (false-negatives). Postoperative duplex ultrasound scans showed six incompetent perforating veins (four persisting and two recurring perforating veins) in four patients, of which the ulcers did not heal in three. The ulcers of the other 17 patients healed.

CONCLUSIONS

Subfascial endoscopy is an efficient technique in identifying incompetent perforating veins in patients with chronic ulceration of the lower leg. The persistence of incompetent perforating veins is related to failure of ulcer healing.

Validation of duplex ultrasonography in detecting competent and incompetent perforating veins in patients with venous ulceration of the lower leg

PURPOSE

Incompetent perforating veins play an important role in the etiologic mechanism of venous ulceration and recurrent varicose veins. The anatomic and functional status of the venous system can be evaluated by duplex ultrasonography. To determine the value of this technique in the identification of competent and incompetent perforating veins, a prospective study was performed.

METHODS

In patients who underwent subfascial exploration for venous ulceration of the lower leg, the preoperative findings of duplex ultrasonography were compared with the findings at surgical exploration.

RESULTS

In 20 consecutive patients, 42 incompetent and 8 competent perforating veins were detected by duplex ultrasonography. During operation the location of all 50 perforating veins appeared to be predicted correctly. Eleven additional perforating veins that had not been detected by duplex ultrasonography were found during operation. The sensitivity and specificity of duplex ultrasonography in predicting the site of perforating veins at the medial side of the lower leg in our study were 79.2% and 100%, respectively, for incompetent perforating veins and 82% and 100%, respectively, for competent and incompetent perforating veins.

CONCLUSION

These figures indicate that duplex-guided local exploration of the lower leg in patients with venous ulceration as a result of incompetent perforating veins would miss a substantial number of perforating veins, possibly leading to incomplete healing or recurrent ulceration.

Prognostic value of dobutamine-atropine stress echocardiography for peri-operative and late cardiac events in patients scheduled for vascular surgery

Cardiac events in the peri-operative phase and late after non-cardiac vascular surgery are a major cause of morbidity and mortality. Numerous tests and diagnostic strategies--usually consisting of a combination of analysis of clinical risk factors and additional non-exercise dependent stress testing, such as thallium scintigraphy, or stress echocardiography--have been developed to preoperatively identify patients with increased risk. The tests ideally should identify three subpopulations in a group with a high prevalence of coronary artery disease; (1) low-risk patients who can be referred for surgery without extra cardiac intervention. (2) patients whose peri-operative cardiac risk outweighs the potential benefits of vascular surgery, (3) patients whose risk may be reduced by peri-operative therapeutic interventions. This review will discuss the prognostic value of dobutamine stress echocardiography for risk stratification in patients scheduled for non-cardiac vascular surgery and discuss guidelines for future management.

Residual arteriovenous fistulae after "closed" in situ bypass grafting: an overrated problem

OBJECTIVES

To prospectively evaluate the incidence and consequences of residual arteriovenous (AV)-fistulae after "closed" in situ bypass grafting.

METHODS

In 34 patients, 35 "closed" in situ bypasses were performed. Postoperative assessment of residual AV-fistulae and bypass patency was performed with duplex scanning.

RESULTS

Postoperative mortality was 3%. During 35 "closed" in situ bypass procedures 216 side branches were coil embolised. Postoperatively 39 AV-fistulae were detected (15% of the total number of 216 + 39 = 255 side branches). Of these, 13 (5%) closed spontaneously. Fifteen (6%) remained unchanged and 11 (4%) were treated. In three patients four asymptomatic residual AV-fistulae were treated. In four patients seven symptomatic AV-fistulae were treated for: decreased distal bypass flow in one; persistent leg oedema in one; pain and redness of the skin in two. One-year primary patency was 80% (SE 8.4%). Residual AV-fistulae were detected in none of six bypass occlusions during follow-up.

CONCLUSION

Residual AV-fistulae detected following "closed" in situ bypass grafting only need treatment if they are symptomatic, which is uncommon.

Comparison of cost affecting parameters and costs of the "closed" and "open" in situ bypass technique

OBJECTIVES

The "closed" in situ bypass results in a reduction of wound complications compared to the "open" technique. This advantage is partly diminished by extra costs for the "closed" procedure and a larger percentage of residual arteriovenous (AV)-fistulae. This aim of this study was to analyse costs related to "closed" and "open" procedures.

METHODS

The cost affecting parameters: (1) duration of operation; (2) length of hospital stay; and (3) number of treated residual AV-fistulae, were analysed in a randomised group of 73 patients (35 "closed" and 38 "open") in two centres. In addition, costs of the operation, nursing care and treatment of AV-fistulae were analysed.

RESULTS

The "closed" and "open" group showed a median duration of operation of 210 min (range 105-570) and 154 min (range 90-355) (p < 0.05), length of hospital stay of 16 days (range 5-51) and 25 days (range 12-65) (p < 0.01), and a percentage of patients treated for residual AV-fistulae of 40% and 5%, respectively (p < 0.01). The median "closed" operation was US$798 more expensive than the "open". Median postoperative care was US$2664 less for the "closed" group. Mean estimated costs for treatment of AV-fistulae was US$9 in the "open" and US$167 in the "closed" group.

CONCLUSION

The "closed" in situ vein bypass technique is cost-effective in comparison with the "open" technique.

Endoscopic ligation of perforating veins using a mediastinoscope

Incompetent perforating veins play a major role in venous ulceration and recurrence of varicose veins. To reduce postoperative wound problems associated with classic subfascial exploration of the lower leg, endoscopic approaches have been developed. We describe a technique that makes use of a mediastinoscope to explore the subfascial area. This inexpensive and readily available instrument is present in most operating rooms. Although a learning curve must be anticipated, the results of this technique in retrospective studies are promising.

Sustained prognostic value of dobutamine stress echocardiography for late cardiac events after major noncardiac vascular surgery

BACKGROUND

Late cardiac events after major noncardiac vascular surgery are an important cause of morbidity and mortality. We studied the prognostic value of preoperative dobutamine stress echocardiography, relative to clinical risk assessment, in predicting late cardiac events.

METHODS AND RESULTS

Three hundred sixteen patients undergoing major vascular surgery were studied. All patients underwent clinical evaluation for the presence of cardiac risk factors (smoking, hypertension, angina, diabetes, history of heart failure, previous infarction, and age > 70 years) and dobutamine stress echocardiography. Left ventricular wall motion was evaluated at rest, and the extent and severity of stress-induced new wall motion abnormalities were quantified. The heart rate threshold at which new wall motion abnormalities occurred was noted. Patients were followed perioperatively and for 19 +/- 11 months postoperatively, and the occurrence of cardiac events was noted. Univariate and multivariate Cox proportional hazards regression models were used to identify predictors of late cardiac events. Thirty-two cardiac events occurred (11 cardiac deaths, 11 nonfatal myocardial infarctions, and 10 incidents of unstable angina). By multivariate regression analysis, the occurrence of extensive (three or more segments) or limited (one or two segments) stress-induced new wall motion abnormalities and previous infarction independently predicted late cardiac events, elevating the risk by 6.5-, 2.9-, and 3.8-fold, respectively. The severity of ischemia during stress and the heart rate threshold for ischemia were not independently predictive.

CONCLUSIONS

Patients with a history of myocardial infarction or stress-induced ischemia have a high risk of fatal and nonfatal cardiac events after vascular surgery. Patients with both a history of infarction and extensive stress-induced ischemia are at especially high risk and deserve intensive management.