Preoperative Coronary Revascularization in High-Risk Patients Undergoing Vascular Surgery: A Core Review

Systematic Preoperative Coronary Angiography in Patients with an Asymptomatic Coronary Artery Disease May be Recommended in Patients with Peripheral Artery Disease Undergoing Open Peripheral Revascularization: A Multicenter Retrospective Study

BACKGROUND

The aim of this study was to retrospectively compare the results of systematic preoperative coronary angiography ultimately followed by stenting in patients with asymptomatic coronary artery disease (CAD) undergoing open peripheral revascularization for peripheral arterial disease (PAD).

METHODS

From January 2003 to December 2022, 276 patients having undergone open peripheral recanalization for PAD were retrospectively reviewed and divided into 2 groups. Patients in group A (n = 132), all without a history of coronary artery disease, had undergone standard cardiac evaluation (EKG and cardiac ultrasound) and systematic preoperative coronary angiography ultimately followed by percutaneous coronary intervention (PCI) for significant coronary artery stenoses, whereas patients in group B (n = 144) had only undergone standard cardiac evaluation prior to open peripheral revascularization. Mean length of follow-up was 60 months (range 12-130 months). The primary endpoints were occurrence of any long-term postoperative myocardial infarction (MI) and any complication related to coronary angiography and stenting. Secondary endpoints were long-term postoperative mortality, complications related to open peripheral revascularization and long-term peripheral bypass patency.

RESULTS

Fifty-three patients (40.0%; 95% CI: 32.0%, 48.0%) in group A had a significant coronary artery stenosis, 48(36.3%; 95% CI: 32.0%, 48.0%) underwent percutaneous intervention (PCI) and 5 (3.8%; 95% CI: 0.5%, 7.0%) received coronary artery bypass grafting (CABG) before open revascularization. While no postoperative MI was observed in group A, seven MI occurred in group B (4.9%; 95% CI: 1.4%, 8.4%), one of which was fatal (P = 0.04). During the follow-up period, 2 non-fatal MI (1.5%; 95% CI: 1.2%, 1.8%) occurred in group A, while 20 MI (14.1%; 95% CI: 8.5%, 19.7%) occurred in group B, 5 of which were fatal (P = 0.0001). No complications related to coronary angiography and stenting were observed. While no postoperative mortality was observed in group A, 2 patients (1.4%; 95% CI: -0.5%, 3.3%) in group B died, one due to a fatal MI and one due to an acute lower limb ischemia and multiple organ failure (P = 0.17). During follow-up, 7 deaths (5.3%; 95% CI: 1.5%, 9.1%) occurred in group A (5 related to cancer, one to lung disease and one for unknown causes) and 16 (11.0%; 95% CI: 6.0%, 16.0%) in group B (5 related to MI, 8 to cancer, and 2 of unknown causes) (P = 0.07). Concerning complications related to open peripheral revascularization, 2 compartmental syndromes (1.5%; 95% CI: -0.5%, 2.5%) occurred in group A and 2 (1.4%; 95% CI: -0.5%, 2.5%) in group B (P = 0.93) in group B (P = 0.93), without indication to perform fasciotomy, no prosthetic infection was observed in either group, and one bypass occlusion (0.7%; 95% CI: -0.7%, 2.1%) occurred in group B with acute lower limb ischemia (P = 0.34). Peripheral bypasses were patent in 90 patients in group A (68.0%; 95% CI: 64.0%, 72.0%) and in 96 patients (67%; 95% CI: 59.4%, 74.6%) in group B (P = 0.78).

CONCLUSION

Systematic preoperative coronary angiography ultimately followed by PCI in patients selected for open lower limb revascularization is safe and reduces intraoperative and postoperative risk of MI.

An Unusual Cause of Coronary Occlusion During an Abdominal Aortic Aneurysm Repair: Reperfusion With Diagnostic Angiography Only

We present a unique case of a type I peri-operative myocardial infarction during an extensive abdominal aortic aneurysm repair occurring due to the occlusion of a severe stable ostial plaque stenosis by a small overlying thrombus. During coronary angiography, the thrombus was dislodged by the diagnostic catheter which restored normal flow without stent placement. We demonstrate a care approach that was carefully arrived upon through multidisciplinary management with vascular surgery and anesthesiology colleagues.

Periprocedural Stroke and Myocardial Infarction as Risks for Long-Term Mortality in CREST

BACKGROUND

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) previously reported increased mortality in patients who sustained a periprocedural stroke or cardiac event (myocardial infarction [MI] or biomarker only) in follow-up to 4 years. We now extend these observations to 10 years.

METHODS AND RESULTS

CREST is a randomized controlled trial designed to compare the outcomes of carotid stenting versus carotid endarterectomy. Proportional hazards models were used to assess the association between mortality and periprocedural stroke, MI, or biomarker-only events. For 10-year follow-up, patients with periprocedural stroke were at 1.74× the risk of death compared with those without stroke (adjusted hazard ratio [HR]=1.74; 95% CI, 1.21-2.50; P<0.003). This increased risk was driven by increased early (between 0 and 90 days) mortality (adjusted HR=14.41; 95% CI, 5.33-38.94; P<0.0001), with no significant increase in late (between 91 days and 10 years) mortality (adjusted HR=1.40; 95% CI, 0.93-2.10; P=0.11). Patients with a protocol MI were at 3.61× increased risk of death compared with those without MI (adjusted HR=3.61; 95% CI, 2.28-5.73; P<0.0001), with an increased hazard both early (adjusted HR=8.20; 95% CI, 1.86-36.2; P=0.006) and late (adjusted HR=3.40; 95% CI, 2.09-5.53; P<0.0001). Patients with a biomarker-only event were at 2.04× increased risk overall (adjusted HR=2.04; 95% CI, 1.09-3.84; P=0.03) than those without MI, with an increased early hazard (adjusted HR=8.44; 95% CI, 1.09-65.5; P=0.04) and a suggestive but nonsignificant association toward higher 91-day to 10-year risk (1.88; 95% CI, 0.97-3.64; P=0.062) contributing to the increased risk.

CONCLUSIONS

In the CREST trial, patients with periprocedural events demonstrate a substantial increase in future mortality to 10 years. For stroke, this risk is largely confined to an early time frame while periprocedural MI or biomarker-only events confer a continuous increased mortality for 10 years. Strategies to reduce periprocedural events and to optimize the evaluation and management of patients with cardiac events should be considered in efforts to reduce not only early but also long-term mortality.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT00004732.

Incidence of Myocardial Infarction After High-Risk Vascular Operations in Adults

Importance

Advances in perioperative cardiac management and an increase in the number of endovascular procedures have made significant contributions to patients and postoperative myocardial infarction (POMI) risk following high-risk vascular procedures. Whether these changes have translated into real-world improvements in POMI incidence remain unknown.

Objective

To examine the temporal trends of myocardial infarction (MI) following high-risk vascular procedures.

Design, Setting, and Participants

A retrospective cohort study was performed using data collected from January 1, 2005, to December 31, 2013, in the American College of Surgeons National Surgery Quality Improvement Program database, to which participating hospitals across the United States report their preoperative, operative, and 30-day outcome data. A total of 90 303 adults who underwent a high-risk vascular procedure-open aortic surgery or infrainguinal bypass-during the study period were identified. Patients were divided into cohorts based on their year of operation, and their baseline cardiac risk factors and incidence of POMI were compared. Cases from 2005 to 2014 in the database were eligible for inclusion if one of their Current Procedural Terminology codes matched any of the operations identified as a high-risk vascular procedure. Data analysis took place from August 1, 2016, to November 15, 2016.

Exposures

The main exposure was the year of the operation. Other variables of interest included demographics, comorbidities, and other risk factors for MI.

Main Outcomes and Measures

Primary outcome of interest was the incidence of POMI.

Results

Of the 90 303 patients included in the study, 22 836 (25.3%) had undergone open aortic surgery and 67 467 (74.7%) had had infrainguinal bypass. The open aortic cohort comprised 16 391 men (71.9%), had a mean (SD) age of 69.1 (11.5) years, and was predominantly white (18 440 patients [80.8%] self-identified as white race/ethnicity). The infrainguinal bypass cohort included 41 845 men (62.1%), had a mean (SD) age of 66.7 (11.7) years, and had 51 043 patients (75.7%) who self-identified as white race/ethnicity. During the study period, patients who underwent open aortic procedures were more likely to be classified as American Society of Anesthesiologists class IV (7426 patients [32.6%] vs 15 683 [23.3%] for the infrainguinal bypass cohort) or class V (1131 [5.0%] vs 206 [0.3%]; P < .001) and to undergo emergency procedures (4852 [21.3%] vs 4954 [7.3%]; P < .001). The open aortic procedure cohort also experienced significantly higher actual incidence of POMI (464 [3.0%] vs 1270 [1.9%]; P < .001). From 2009 to 2014, the incidence of POMI demonstrated no substantial temporal change (2.7% in 2009 to 3.1% in 2014; P = .64 for trend). Postoperative MI was consistently associated with poor prognosis, with a 3.62-fold (95% CI, 2.25-5.82) to 11.77-fold (95% CI, 6.10-22.72) increased odds of cardiac arrest and a 3.01-fold (95% CI, 2.08-4.36) to 6.66-fold (95% CI, 4.66-9.52) increased odds of mortality.

Conclusions and Relevance

The incidence of MI did not significantly decrease in the past decade and has been consistently associated with worse clinical outcomes. Further inquiry into why advanced perioperative care did not reduce cardiac complications is important to quality improvement efforts.

Anesthesia for Patients with Peripheral Vascular Disease and Cardiac Dysfunction

Patients with vascular disease and cardiac dysfunction present particular challenges to the anesthesiologist. They are hemodynamically brittle, at high risk of morbidity and mortality during surgery, and often carry additional comorbidities that increase their complexity and risk. Those with peripheral vascular disease should be assumed to have coronary artery disease and tend to have other systemic vascular problems. Poor cardiac function further worsens perfusion in an already compromised peripheral vascular system. Care of these patients requires judicious monitoring, an anesthetic that optimizes hemodynamic function, and avoidance of particularly likely complications such as perioperative myocardial ischemia, stroke, and bleeding.

Frequency of concomitant ischemic heart disease and risk factor analysis for an early postoperative myocardial infarction after elective abdominal aortic aneurysm repair

Purpose

We aimed to see the frequency of concomitant ischemic heart disease (IHD) in Korean patients with abdominal aortic aneurysm (AAA) and to determine risk factors for an early postoperative acute myocardial infarction (PAMI) after elective open or endovascular AAA repair.

Methods

We retrospectively reviewed a database of patients who underwent elective AAA repair over the past 11 years. Patients were classified into 3 groups: control group; group I, medical IHD treatment; group II, invasive IHD treatment. Rates of PAMI and mortality at 30 days were compiled and compared between groups according to the type of AAA repair.

Results

Six hundred two elective repairs of infrarenal or juxtarenal AAAs were enrolled in this study. The patients were classified into control group (n = 398, 66.1%), group I (n = 73, 12.1%) and group II (n = 131, 21.8%). PAMI developed more frequently after open surgical repair (OSR) than after endovascular aneurysm repair (EVAR) (5.4% vs. 1.3%, P = 0.012). In OSR patients (n = 373), PAMI developed 2.1% in control group, 18.0% in group I and 7.1% in group II (P < 0.001). In EVAR group (n = 229), PAMI developed 0.6% in control group, 4.3% in group I and 2.2% in group II (P = 0.211). On the multivariable analysis of risk factors of PAMI, PAMI developed more frequently in patients with positive functional stress test.

Conclusion

The prevalence of concomitant IHD was 34% in Korean AAA patients. The risk of PAMI was significantly higher after OSR compared to EVAR and in patients with IHD compared to control group. Though we found some risk factors for PAMI, these were not applied to postoperative mortality rate.

Preoperative coronary revascularization for the reduction of perioperative ischemic complications in patients undergoing major vascular surgery

Patients undergoing vascular surgery are at increased risk for perioperative cardiac complications related to the frequent prevalence of underlying coronary artery disease. Cardiac evaluation and noninvasive tests may often identify patients at increased cardiac risk in whom coronary angiography is often considered with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, there has been controversy as to the indications and efficacy for type of revascularization and how coronary revascularization may add to the effect of optimized medical therapy for the reduction of cardiac complications. The aim of this review is to summarize the role of preoperative coronary revascularization in the reduction of perioperative cardiac complications in patients with coronary artery disease undergoing major vascular surgery.

[Perioperative myocardial damage in non-cardiac surgery patients]

Perioperative myocardial damage occurs with a high incidence depending on the operative procedure and the patients examined and is considered to be among the most relevant risk factors for increased perioperative morbidity and mortality in patients undergoing non-cardiac surgery. The pathophysiology of myocardial damage in the perioperative period is still not well understood. Both ischemia with and without acute coronary occlusion and non-ischemic stimuli can put a substantial strain on the heart in the perioperative period. However, in many cases the clinical presentation does not allow a clear differentiation between ischemic and non-ischemic myocardial damage. In the majority of cases perioperative myocardial infarctions occur with only mild or even without any clinical symptoms. This is probably due to a considerable difference in phenotype and pathophysiology between perioperative and non-perioperative myocardial infarctions. As a result of this unexplained etiology of perioperative myocardial infarction it remains an open question whether the contemporary diagnostic and therapeutic recommendations for the acute coronary syndrome can be extrapolated to the perioperative situation. The present review reflects the current state of knowledge and presents an optional approach to the diagnosis and therapy of perioperative myocardial injury.

[Preoperative revascularization in high-risk patients undergoing vascular surgery]

Patients undergoing vascular surgery are at increased risk for cardiac complications related to the presence of underlying coronary artery disease. Preoperative cardiac evaluation may help to identify high-risk patients in whom coronary angiography may be planned with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, the indications and efficacy for type of revascularization for the reduction of cardiac complications compared to medical therapy have been controversial. The aim of the review was to summarize the role of preoperative revascularization compared to conservative medical therapy before elective vascular surgery using current evidence from published studies.