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• W2063300916 abstract "Since the seminal work of Hertzer et al. 1Hertzer NR Young JR Kramer JR et al.Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease.Arch Surg. 1979; 114: 1336-1344Crossref PubMed Scopus (180) Google Scholar, 2Hertzer NR Beven EG Young JR et al.Coronary artery disease in peripheral vascular patients. A classification of 1000 coronary angiograms and results of surgical management.Ann Surg. 1984; 199: 223-233Crossref PubMed Scopus (1196) Google Scholar in the early 1980s, vascular surgeons have accepted the fact that patients with peripheral vascular disease frequently have concomitant coronary artery disease. Some studies, however, have suggested that despite the presence of coronary artery disease, vascular reconstructive surgery can be undertaken with low morbidity and mortality, and that routine coronary angiography and prophylactic revascularization is unnecessary and, indeed, unjustified. 3Brown OW Hollier LH Pairolero PC et al.Abdominal aortic aneurysm and coronary artery disease: a reassessment.Arch Surg. 1981; 116: 1484-1488Crossref PubMed Scopus (153) Google Scholar, 4Reigel MM Hollier LH Kazmier FJ et al.Late survival in abdominal aortic aneurysm patients: the role of selective myocardial revascularization on the basis of clinical symptoms.J VASC SURG. 1987; 5: 222-227PubMed Scopus (121) Google Scholar In these latter studies, we noted that the cardiac-related mortality rate after major aortic reconstruction in patients who had no history of coronary artery disease by clinical assessment alone was only 0.8%. In addition, even those patients who had clinical evidence of coronary artery disease on the basis of symptomatology or electrocardiographic (ECG) changes underwent aortic reconstruction, with a cardiac-related mortality rate of less than 3%. 3Brown OW Hollier LH Pairolero PC et al.Abdominal aortic aneurysm and coronary artery disease: a reassessment.Arch Surg. 1981; 116: 1484-1488Crossref PubMed Scopus (153) Google Scholar, 4Reigel MM Hollier LH Kazmier FJ et al.Late survival in abdominal aortic aneurysm patients: the role of selective myocardial revascularization on the basis of clinical symptoms.J VASC SURG. 1987; 5: 222-227PubMed Scopus (121) Google Scholar Since these early reports, however, accurate noninvasive means of functional cardiac assessment have gained widespread use. Previously, exercise electrocardiography was the mainstay of functional assessment of the myocardium. Clearly, this had limited applicability in elderly patients whose frailty or claudication status limited their ability to exercise to a satisfactory level. Multigated radionuclide scans, although useful in determining left ventricular ejection fraction (LVEF), could not really provide an adequate assessment of the extent of myocardium at risk from possible occlusive lesions; we still do use these scans to evaluate LVEF in selected patients, particularly those with a history of congestive failure. Currently dipyridamole-thallium scans have gained increasing acceptance as a valuable and reliable noninvasive technique to assess the functional significance of coronary artery stenoses. 5Boucher CA Brewster DC Darling RC et al.Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery.N Engl J Med. 1985; 312: 389Crossref PubMed Scopus (559) Google Scholar, 6Eagle KA Singer DE Brewster DC et al.Dipyridamolethallium scanning in patients undergoing vascular surgery.JAMA. 1987; 257: 2185Crossref PubMed Scopus (271) Google Scholar, 7Leppo J Plaja J Gionet M et al.Noninvasive evaluation of cardiac risk before elective vascular surgery.J Am Coll Cardiol. 1987; 9: 269-276Abstract Full Text PDF PubMed Scopus (261) Google Scholar, 8Cutler BS Leppo JA. Dipyridamole-thallium 201 scintigraphy to detect coronary artery disease before abdominal aortic surgery.J VASC SURG. 1987; 5: 91PubMed Scopus (174) Google Scholar, 9Cambria RP Brewster DC Abbott WM et al.The impact of selective use of dipyridamole-thallium scans and surgical factors on the current morbidity of aortic surgery.J VASC SURG. 1992; 15: 43-51Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Boucher et al.5Boucher CA Brewster DC Darling RC et al.Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery.N Engl J Med. 1985; 312: 389Crossref PubMed Scopus (559) Google Scholar noted eight cardiac events occurring among 16 patients who had a positive dipyridamole-thallium scan outcomes compared with no cardiac events occurring among 32 patients who had a negative scan outcome. In a similar manner Eagle et al.6Eagle KA Singer DE Brewster DC et al.Dipyridamolethallium scanning in patients undergoing vascular surgery.JAMA. 1987; 257: 2185Crossref PubMed Scopus (271) Google Scholar noted a 44.4% incidence of a postoperative ischemic event after aortic surgery among the 18 patients in their series who had evidence of redistribution on a dipyridamole-thallium scan; in contrast, only one of 43 patients with a negative scan result had a postoperative ischemic event. Leppo et al.7Leppo J Plaja J Gionet M et al.Noninvasive evaluation of cardiac risk before elective vascular surgery.J Am Coll Cardiol. 1987; 9: 269-276Abstract Full Text PDF PubMed Scopus (261) Google Scholar and Cutler and Leppo8Cutler BS Leppo JA. Dipyridamole-thallium 201 scintigraphy to detect coronary artery disease before abdominal aortic surgery.J VASC SURG. 1987; 5: 91PubMed Scopus (174) Google Scholar demonstrated in 100 patients who underwent preoperative dipyridamole-thallium scans that the odds of a cardiac event in the postoperative period were 23 times greater if they had a positive dipyridamole-thallium scan. Cambria et al.9Cambria RP Brewster DC Abbott WM et al.The impact of selective use of dipyridamole-thallium scans and surgical factors on the current morbidity of aortic surgery.J VASC SURG. 1992; 15: 43-51Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar have also presented clinical data wherein patients selected on clinical criteria underwent preoperative dipyridamole-thallium scanning before vascular reconstruction; with use of positive redistribution as a method of identifying patients at high risk, they were able to select patients in need of coronary revascularization. Their overall need for coronary revascularization, however, was low (9%), and the results of the vascular reconstructive procedures were excellent (2% operative mortality rate).9Cambria RP Brewster DC Abbott WM et al.The impact of selective use of dipyridamole-thallium scans and surgical factors on the current morbidity of aortic surgery.J VASC SURG. 1992; 15: 43-51Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar All of these data are clearly impressive and suggest that we do have a simple, safe, and efficient way of identifying a subgroup of patients with vascular disease who might be at increased risk of myocardial infarction. Identification of a critical coronary artery stenosis might imply that surgical correction of the coronary lesion must be undertaken before performing a vascular reconstructive procedure. However, data from the CASS study documented that coronary revascularization, particularly in elderly patients with vascular disease, was in itself associated with significant morbidity and mortality rates. 10Kennedy JW Kaiser GC Fisher LD et al.Multivariate discriminant analysis of the clinical and angiographic predictors of operative mortality from the collaborative study in coronary artery surgery (CASS).J Thorac Cardiovasc Surg. 1980; 80: 876-887PubMed Google Scholar, 11Kennedy JW Kaiser GC Fisher LD et al.Clinical and angiographic predictors of operative mortality from the collaborative study in coronary artery surgery (CASS).Circulation. 1981; 63: 793-802Crossref PubMed Scopus (311) Google Scholar, 12Gersh BJ Kronma RA Frye RL et al.Coronary arteriography and coronary artery bypass surgery: morbidity and mortality in patients ages 65 years or older. A report from the Coronary Artery Surgery Study.Circulation. 1983; 67: 483-491Crossref PubMed Scopus (238) Google Scholar, 13Knapp WS Douglas Jr, JS Carver JM et al.Efficacy of coronary artery bypass grafting in elderly patients with coronary artery disease.Am J Cardiol. 1981; 47: 923-930Abstract Full Text PDF PubMed Scopus (63) Google Scholar The operative mortality rate for coronary bypass grafting increases significantly with age, being 4.5% for ages 65 to 69 years, 6.3% for ages 70 to 74 years, and 9.8% for patients 75 years of age or older.12Gersh BJ Kronma RA Frye RL et al.Coronary arteriography and coronary artery bypass surgery: morbidity and mortality in patients ages 65 years or older. A report from the Coronary Artery Surgery Study.Circulation. 1983; 67: 483-491Crossref PubMed Scopus (238) Google Scholar It is clear that in many patients with vascular disease, particularly the elderly or those with very low LVEF, it is difficult to justify prophylactic coronary angiography and coronary revascularization on a routine basis, because the risk of coronary bypass is sometimes higher than the risk of simply proceeding with vascular reconstruction. 3Brown OW Hollier LH Pairolero PC et al.Abdominal aortic aneurysm and coronary artery disease: a reassessment.Arch Surg. 1981; 116: 1484-1488Crossref PubMed Scopus (153) Google Scholar, 4Reigel MM Hollier LH Kazmier FJ et al.Late survival in abdominal aortic aneurysm patients: the role of selective myocardial revascularization on the basis of clinical symptoms.J VASC SURG. 1987; 5: 222-227PubMed Scopus (121) Google Scholar, 14Taylor Jr, LM Yeager RA Moneta GL et al.The incidence of perioperative myocardial infarction in general vascular surgery.in: Presented at the Joint Annual MeetingJune 2–5, 1991Google Scholar However, percutaneous transluminal coronary angioplasty has recently shown dramatic improvement in safety and successful correction of some coronary lesions, at least over the short term. At our institution approximately 60% of patients with coronary artery lesions, severe enough to warrant invasive treatment, are managed by angioplasty rather than coronary artery bypass. In view of this, the surgeon must consider the possible option of balloon angioplasty of a truly critical coronary lesion before undertaking vascular reconstruction. Ultimately, the issue is a question of surgical judgement wherein one must balance the risks of preoperative testing and prophylactic intervention versus the chance of missing a lethal disorder, such as left main or three-vessel coronary artery disease, and the risk of a vascular operation in a specific patient. Our approach to the preoperative cardiac evaluation of a patient with vascular disease is based primarily on clinical criteria. Patients are initially screened for any history of prior myocardial infarction, previous or concurrent episodes of angina or congestive heart failure, and symptoms of possible cardiac rhythm disturbance. Physical examination focuses on evidence of arrhythmia, congestive failure, or valvular heart disease. The ECG is examined for evidence of arrhythmia or prior myocardial infarction and signs of any ongoing myocardial ischemia. We carefully evaluate the patient's lifestyle and level of activity. If a patient is found to have no prior history or concurrent symptoms of coronary artery disease, and if the patient leads an active and vigorous lifestyle (e.g., active laborer, tennis player, and the like) and if the ECG and chest radiography results are normal, we would subject the patient to a vascular procedure without further cardiac evaluation. On the other hand, patients who have class III or class IV angina or who have symptoms of recent episodes of congestive failure would usually undergo coronary angiography and ventriculography before a vascular procedure, without the performance of an intervening noninvasive cardiac study. Between these two extremes, however, lie a large number of patients who either have mild, stable symptoms of coronary artery disease or who are asymptomatic but lead a very sedentary lifestyle wherein they might never perform enough activity to elicit any significant symptoms of myocardial ischemia. It is these patients whom we feel are most likely to benefit from a noninvasive cardiac study. In these patients we will routinely attempt to perform a dipyridamole-thallium scan, requesting further diagnostic studies or proceeding with vascular surgery on the basis of that scan (Figs. 1 and 2).Fig. 2Schematic of decision tree for patients who undergo dipyridamole-thallium scanning for cardiac evaluation before vascular surgery (PTCA, Percutaneous transluminal coronary angioplasty; CABG, coronary artery bypass grafting).View Large Image Figure ViewerDownload Hi-res image Download (PPT) If a patient has significant redistribution on dipyridamole-thallium scanning, suggesting a critical segment of myocardium at risk, we will generally proceed to coronary angiography. If the coronary angiogram shows significant coronary lesions and a reconstructible situation, the patient will then be urged to undergo percutaneous transluminal coronary angioplasty, if possible, or coronary artery bypass grafting. If coronary angiography discloses noncritical or nonreconstructible coronary lesions, or if the patient declines coronary revascularization, we will then proceed with the vascular procedure with the concurrent use of maximum cardiac monitoring and pharmacologic support. Consideration would also be given to performing an alternative, less stressful, or minimally invasive procedure. It is also important to note that, in those patients who have poor ventricular function or in the very elderly (i.e., those over 80 years of age), in whom coronary artery bypass grafting would carry a particularly high risk, we will generally elect to proceed directly with vascular surgery, under intense monitoring, and forego any preliminary attempts at prophylactic myocardial revascularization, unless a simple percutaneous transluminal coronary angioplasty would be feasible. Most discussions regarding the prophylactic management of coronary artery disease in patients with vascular abnormalities has presupposed the need for a direct vascular reconstruction, such as repair of an abdominal aortic aneurysm. For occlusive disease, however, surgeons frequently have additional options such as extraanatomic bypass or balloon angioplasty. For example, patients with significant coronary disease and iliac lesions may be better served by angioplasty of the iliac lesion rather than direct surgical reconstruction. Similarly, severe aortoiliac occlusive disease not amenable to angioplasty might prompt the surgeon to perform an extraanatomic bypass rather than direct aortic reconstruction if the patient represents high cardiac risk. Ultimately, despite the advances in diagnostic technology, the surgeon must provide the informed judgment to identify the appropriate procedure taking into account all factors, including overall cardiac risk, the specific vascular disease, the severity of patient symptoms, and the various options of surgical and minimally invasive treatment modalities. In summary, we support the selective use of noninvasive cardiac evaluation in patients with vascular disease, based on clinical evaluation and categorization of risks. Those with severe angina and those with positive dipyridamole-thallium scan outcomes are further evaluated by coronary angiography. However, prophylactic myocardial revascularization is limited to those patients who appear to have truly critical lesions that might pose a threat to the life of the patient or result in the loss of significant myocardial function. Other patients are offered vascular reconstruction without prophylactic myocardial revascularization, but with the use of intensive perioperative monitoring and pharmacologic support." @default.
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• W2063300916 title "Cardiac evaluation in patients with vascular disease—Overview: A practical approach" @default.
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