Usefulness of revascularization of patients with multivessel coronary artery disease before elective vascular surgery for abdominal aortic and peripheral occlusive disease.

The Coronary Artery Revascularization Prophylaxis (CARP) study showed no survival benefit with preoperative coronary artery revascularization before elective vascular surgery. The generalizability of the trial results to all patients with multivessel coronary artery disease (CAD) has been questioned. The objective of this study was to determine the impact of prophylactic coronary revascularization on long-term survival in patients with multivessel CAD. Over a 4-year period, 1,048 patients underwent coronary angiography before vascular surgery during screening into the CARP trial. The cohort was composed of registry (n = 586) and randomized (n = 462) patients, and their survival was determined at 2.5 years after vascular surgery. High-risk coronary anatomy without previous bypass surgery included 2-vessel disease (n = 204 [19.5%]), 3-vessel disease (n = 130 [12.4%]), and left main coronary artery stenosis > or = 50% (n = 48 [4.6%]). By log-rank test, preoperative revascularization was associated with improved survival in patients with a left main coronary artery stenoses (0.84 vs 0.52, p <0.01) but not those with either 2-vessel (0.80 vs 0.79, p = 0.83) or 3-vessel (0.79 vs 0.71, p = 0.15) disease. In conclusion, unprotected left main coronary artery disease was present in 4.6% of patients who underwent coronary angiography before vascular surgery, and this was the only subset of patients showing a benefit with preoperative coronary artery revascularization.

Predictors and outcomes of a perioperative myocardial infarction following elective vascular surgery in patients with documented coronary artery disease: results of the CARP trial.

AIMS: The predictors and outcomes of patients with a peri-operative elevation in cardiac troponin I above the 99th percentile of normal following an elective vascular operation have not been studied in a homogeneous cohort with documented coronary artery disease. METHODS AND RESULTS: The Coronary Artery Revascularization Prophylaxis (CARP) trial was a randomized trial that tested the benefit of coronary artery revascularization prior to vascular surgery. Among 377 randomized patients, core lab samples for peak cardiac troponin I concentrations were monitored following the vascular operation and the blinded results were correlated with outcomes. A peri-operative myocardial infarction (MI), defined by an increase in cardiac troponin I greater than the 99th percentile reference (> or =0.1 microg/L), occurred in 100 patients (26.5%) and the incidence was not dissimilar in patients with and without pre-operative coronary revascularization (24.2 vs. 28.6%; P = 0.32). By logistic regression analysis, predictors of MI (odds risk; 95%CI; P-value) were age >70 (1.84; 1.14-2.98; P = 0.01), abdominal aortic surgery (1.82; 1.09-3.03; P = 0.02), diabetes (1.86; 1.11-3.11; P = 0.02), angina (1.67; 1.03-2.64; P = 0.04), and baseline STT abnormalities (1.62; 1.00-2.6; P = 0.05). At 2.5 years post-surgery, the probability of survival in patients with and without the MI was 0.73 and 0.84, respectively (P = 0.03, log-rank test). Using a Cox proportional hazards regression analysis, a peri-operative MI in diabetic patients was a strong predictor of long-term mortality (hazards ratio: 2.43; 95% CI: 1.31-4.48; P < 0.01). CONCLUSION: Among patients with coronary artery disease who undergo vascular surgery, a peri-operative elevation in cardiac troponin levels is common and in combination with diabetes, is a strong predictor of long-term mortality. These data support the utility of cardiac troponins as a means of stratifying high-risk patients following vascular operations.

Coronary artery bypass grafting is superior to percutaneous coronary intervention in prevention of perioperative myocardial infarctions during subsequent vascular surgery.

BACKGROUND: Among patients in need of coronary revascularization before an elective vascular operation, the value of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in preventing perioperative myocardial infarctions is uncertain. We hypothesized that more complete revascularization would improve outcomes after vascular surgery. METHODS: In this Veterans Affairs Cooperative trial involving 18 medical centers, 222 patients underwent elective vascular surgery after coronary revascularization. The mode of coronary revascularization was selected at each site by the local investigators (CABG in 91 patients and PCI in 131 patients). The vascular surgical indications were similar in both groups. RESULTS: There were 2 deaths in the CABG group (2.2%) and 5 deaths in the PCI group (3.8%; p = 0.497) after the vascular procedure. There were fewer perioperative myocardial infarctions after the vascular operation in CABG patients (6.6%) than in PCI patients (16.8%; p = 0.024), despite more diseased vessels in the CABG group (3.0 +/- 1.3 versus 2.2 +/- 1.4, respectively; p < 0.001). The completeness of revascularization (defined as the number of coronary artery vessels revascularized relative to the total number of vessels with a stenosis > or = 70%) in patients in the CABG and PCI groups was 117% +/- 63% and 81% +/- 57%, respectively (p < 0.001). Hospital length of stay in CABG versus PCI patients was 6 (4, 8) and 7 (4, 10) days, respectively (p = 0.078). CONCLUSIONS: Among patients receiving multivessel coronary artery revascularization as prophylaxis for elective vascular surgery, patients having a CABG had fewer myocardial infarctions and tended to spend less time in the hospital after the vascular operation than patients having a PCI. More complete revascularization accounted for the intergroup differences.

Postoperative outcomes for patients undergoing elective revascularization for critical limb ischemia and intermittent claudication: a subanalysis of the Coronary Artery Revascularization Prophylaxis (CARP) trial.

OBJECTIVE: To determine the perioperative mortality, myocardial infarction rate, and long-term survival of patients with critical limb ischemia (CLI) compared with those with intermittent claudication (IC) within a cohort selected for significant coronary artery disease, a secondary analysis was conducted of a prospective, randomized, multicenter trial of Coronary Artery Revascularization Prophylaxis (CARP) before peripheral vascular surgery. This multicenter trial was sponsored by the Cooperative Studies Program of the Department of Veterans Affairs. METHODS: Of the 510 patients enrolled in the CARP trial and randomized to coronary revascularization or no revascularization before elective vascular surgery, 143 had CLI and 164 had IC as an indication for lower limb revascularization; >95% of each group were men. The presence of coronary artery disease was determined by cardiac catheterization. Eligible patients had at least one treatable coronary lesion of > or =70%. Those with significant left main disease, ejection fraction of <20%, and aortic stenosis were excluded. Patients were randomized to coronary artery disease revascularization or no revascularization before vascular surgery and followed for mortality and morbidity perioperatively and for a median of 2.7 years postoperatively. Medical treatment of coronary artery disease was pursued aggressively. RESULTS: Patients with IC had a longer time from randomization to vascular surgery (p = .001) and more abdominal operations (p < .001). Patients with CLI had more urgent operations (p = .006), reoperations (p < .001), and limb loss (p = .008) as well as longer hospital stays (p < .001). The IC group had more perioperative myocardial infarctions (CLI, 8.4%; IC, 17.1%; p = .024), although perioperative mortality was similar (CLI, 3.5%; IC, 1.8%; p = .360). In follow-up, the IC group also had numerically more myocardial infarctions (CLI, 16.8%; IC, 25%; p = .079), but mortality was not different (CLI, 21%; IC, 22%; p = .825). Coronary artery revascularization did not lower perioperative or long-term mortality in either group. CONCLUSIONS: Our data indicate that patients with significant coronary artery disease and either CLI or IC can undergo vascular surgery with low mortality and morbidity, and these results are not improved by coronary artery revascularization before vascular surgery. Furthermore, when selected for the presence of symptomatically stable, severe coronary artery disease, there is no difference in long-term survival between patients with CLI and IC. Finally, the better-than-predicted outcomes for these patients with advanced systemic atherosclerosis may be due to aggressive medical management with beta-blockers, statins, and acetylsalicylic acid.

Coronary-artery revascularization before elective major vascular surgery.

BACKGROUND: The benefit of coronary-artery revascularization before elective major vascular surgery is unclear. METHODS: We randomly assigned patients at increased risk for perioperative cardiac complications and clinically significant coronary artery disease to undergo either revascularization or no revascularization before elective major vascular surgery. The primary end point was long-term mortality. RESULTS: Of 5859 patients scheduled for vascular operations at 18 Veterans Affairs medical centers, 510 (9 percent) were eligible for the study and were randomly assigned to either coronary-artery revascularization before surgery or no revascularization before surgery. The indications for a vascular operation were an expanding abdominal aortic aneurysm (33 percent) or arterial occlusive disease of the legs (67 percent). Among the patients assigned to preoperative coronary-artery revascularization, percutaneous coronary intervention was performed in 59 percent, and bypass surgery was performed in 41 percent. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the group not undergoing revascularization (P<0.001). At 2.7 years after randomization, mortality in the revascularization group was 22 percent and in the no-revascularization group 23 percent (relative risk, 0.98; 95 percent confidence interval, 0.70 to 1.37; P=0.92). Within 30 days after the vascular operation, a postoperative myocardial infarction, defined by elevated troponin levels, occurred in 12 percent of the revascularization group and 14 percent of the no-revascularization group (P=0.37). CONCLUSIONS: Coronary-artery revascularization before elective vascular surgery does not significantly alter the long-term outcome. On the basis of these data, a strategy of coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended.

Disparate opinions regarding indications for coronary artery revascularization before elective vascular surgery.

Despite consensus guidelines, the optimal strategy for preoperative cardiac risk management among patients scheduled for major noncardiac surgery remains controversial. This study assesses current opinion about the role of preoperative coronary revascularization for patients with coronary artery disease scheduled for elective vascular surgery. Thirty-one practicing cardiologists recruited from 4 different regions reviewed case records, imaging tests, and coronary angiograms of 12 patients with coronary artery disease participating in the Coronary Artery Revascularization Prophylaxis (CARP) trial. The need for preoperative coronary revascularization was determined and results summarized using 3 categories: favoring conservative management, neutral, or recommending revascularization (either by percutaneous intervention or bypass surgery). We found recommendations were frequently disparate and often deviated from published guidelines (40% of the time). The likelihood of discordance between 2 cardiologists was 54%, with a 26% chance that recommendations for revascularization would be directly contradictory. Opinions were more often conservative (43%) or aggressive (40%) than neutral (17%). Similar inconsistency was found as to the preferred method of revascularization, with only 1 patient having complete agreement. Thus, this study reveals substantial differences of opinion among cardiologists across the country about the role of preoperative coronary artery revascularization for patients scheduled for elective vascular operations. Deviations from published guidelines are common, suggesting that current consensus statements need additional data to support their recommendations.

Functional outcome in a contemporary series of major lower extremity amputations.

PURPOSE: We undertook this study to document the functional natural history of patients undergoing major amputation in an academic vascular surgery and rehabilitation medicine practice. METHODS: A retrospective review was conducted of consecutive patients undergoing major lower extremity amputation and rehabilitation in a university and Department of Veterans Affairs hospital. Main outcome variables included operative mortality, follow-up, survival, median time to incision healing, secondary operative procedures for wound management, and conversion from below-knee amputation (BKA) to above-knee amputation (AKA). For surviving patients, quality of life was determined by degree of ambulation, eg, outdoors, indoors only, or no ambulation; use of a prosthesis; and independence, eg, community housing or nursing facility. RESULTS: From August 1997 through March 2002, 154 patients (130 men; median age, 62 years) underwent 172 major amputations, 78 AKA and 94 BKA, because of either critical limb ischemia (87%) or diabetic neuropathy (13%). Thirty-day operative mortality was 10%. Mean follow-up was 14 months. Healing at 100 and 200 days, as determined with the Kaplan-Meier method, was 55% and 83%, respectively, for BKA, and 76% and 85%, respectively, for AKA. Twenty-three BKA and 16 AKA required additional operative revision, and 18 BKA ultimately were converted to AKA. Survival was 78% at 1 year and 55% at 3 years. Function in surviving patients at 10 and 17 months, respectively, was as follows: 21% and 29% of patients ambulated outdoors, 28% and 25% ambulated indoors only, and 51% and 46% of patients were nonambulatory; 32% and 42% of patients used prosthetic limbs; and 17% and 8% of patients who lived in the community before amputation required care in a nursing facility. CONCLUSIONS: We were surprised to find that vascular patients in a contemporary setting who require major lower extremity amputation and rehabilitation often remain independent despite infrequent prosthesis use and outdoor ambulation. Although any hope for postoperative ambulation in this population requires salvaging the knee joint, because of the morbidity incurred in both wound healing and rehabilitation efforts, aggressive effort should be reserved for selected patients at good risk. Ability to predict ambulation after BKA in the vascular population is poor.

Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery.

Decision-making in regard to elective repair of abdominal aortic aneurysms (AAA) requires careful assessment of factors that influence rupture risk, operative mortality, and life expectancy. Individualized consideration of these factors in each patient is essential, and the role of patient preference is of increasing importance. It is not possible or appropriate to recommend a single threshold diameter for intervention which can be generalized to all patients. Based upon the best available current evidence, 5.5 cm is the best threshold for repair in an "average" patient. However, subsets of younger, good-risk patients or aneurysms at higher rupture risk may be identified in whom repair at smaller sizes is justified. Conversely, delay in repair until larger diameter may be best for older, higher-risk patients, especially if endovascular repair is not possible. Intervention at diameter <5.5 cm appears indicated in women with AAA. If a patient has suitable anatomy, endovascular repair may be considered, and it is most advantageous for older, higher-risk patients or patients with a hostile abdomen or other technical factors that may complicate standard open repair. With endovascular repair, perioperative morbidity and recovery time are clearly reduced; however, there is a higher reintervention rate, increased surveillance burden, and a small but ongoing risk of AAA rupture. There is no justification at present for different indications for endovascular repair, such as earlier treatment of smaller AAA. Until long-term outcome of endoluminal repair is better defined and results of randomized trials available, the choice between endovascular and open repair will continue to rely heavily on patient preference.

Outcome of catheter-directed thrombolysis for lower extremity arterial bypass occlusion.

OBJECTIVE: The purpose of this study was to determine the clinical outcome of patients undergoing catheter-directed thrombolysis (CDT) for lower extremity arterial bypass (LEAB) occlusion. METHODS: A retrospective review was performed of two university-based practices from 1988 to 2001. All patients with LEAB occlusion (<14 days by history) undergoing CDT as initial treatment were included. Technical success, complications, secondary patency, and limb salvage were examined. Additional analysis examined secondary procedures performed for residual lesions or failed CDT and the number of LEABs that were replaced or that became infected. RESULTS: One hundred four patients (77% male; mean age, 65 years) had 109 LEAB occlusions. CDT restored patency in 77%. Of the 25 LEABs that failed initial CDT, 15 underwent surgical thrombectomy/revision, four were replaced, and six underwent no further interventions. Of the 84 LEABs successfully lysed, 51 had residual lesions that underwent revision with interventional (n = 30) or surgical (n = 15) techniques or both (n = 6). Median hospital stay was 8 days with three periprocedural deaths. One quarter of CDT procedures had bleeding or thrombotic complications or both. The mean follow-up period was 45 months. Secondary patency rates on an intention-to-treat basis (attempted thrombolysis) were 32% and 19% at 1 and 5 years, respectively. After successful CDT, the 1-year secondary patency rate was comparable in LEABs with or without residual lesions (42% versus 45%). Overall, the limb salvage rates were 73% and 55% at 1 and 5 years, respectively. The survival rate was 56% at 5 years. Ten of the 54 LEABs (19%) that eventually failed after successful CDT had three or more reocclusive episodes. Seven LEABs (8.3%) salvaged with CDT eventually became infected from recurrent interventions; six of these necessitated major amputation. Twenty LEABs initially salvaged with CDT were replaced (four immediately and 16 after episodes of recurrent ischemia). Two patients died during hospitalization for treatment of recurrent ischemia. CONCLUSION: Despite relatively high initial technical success for LEAB thrombolysis, eventual failure is the rule rather than the exception. Recurrent LEAB occlusions lead to significant morbidity, including recurrent interventions, eventual graft infection/replacement, and limb loss. However, LEAB replacement has substantial problems associated with limited conduit, reoperative anatomy, and subsequent wound complications. We therefore advocate an initial attempt at CDT with liberal use of graft replacement for early and late failures or as an initial strategy in those with favorable remaining conduit.

Preoperative cardiac risk management.

Numerous strategies exist for preoperative cardiac testing before patients undergo vascular operations. Potential adverse effects of evaluation and cardiac intervention should be considered before undertaking screening studies. We recently analyzed the adverse outcomes of preoperative cardiac evaluation and intervention before vascular operations in patients treated at the Denver Department of Veterans Affairs Medical Center. During the 12 month study period, 161 patients were scheduled to undergo major vascular operations; 153 patients came to operation. The decision to pursue a cardiac evaluation was made without a defined protocol. Forty two men, aged 68+/-9 years underwent comprehensive preoperative cardiac evaluations Sixteen (38%) patients had untoward events related to cardiac evaluation, including eight patients (19%) who refused vascular surgery after cardiac screening and/or intervention. Other complications included prosthetic graft infection, pseudoaneurysms (2), sternal wound infections (2) amputations (2), renal failure and brain anoxia. Extensive cardiac evaluation prior to vascular operations can result in morbidity, delays, and refusal to undergo vascular surgery. The underlying indication for vascular operations and the local iatrogenic cardiac complication rates must be considered before ordering special studies.

Smoking cessation counseling: a missed opportunity for general surgery trainees.

PURPOSE: The purpose of this study was to evaluate and compare the attitudes, practices, technique utilizations, and barrier perceptions of smoking cessation counseling (SCC) in general surgery (GS) and primary care (PC) residents. METHODS: One hundred house staff officers (45 GC and 55 PC residents, consisting of internal medicine and family medicine disciplines) were randomly surveyed. chi(2) and t tests were used for comparative analysis where appropriate. The National Cancer Institute's recommendation that physicians follow the "four A's" for SCC (Ask, Advise, Assist, and Arrange follow-up) was examined with respect to compliance by surgical and medical residents. RESULTS: Fewer GS than PC residents thought physicians were responsible for SCC (64% versus 85%; P <.02), and fewer felt well prepared to counsel their patients (38% versus 58%; P <.05). Nevertheless, about 85% of both groups reported a higher inclination to provide SCC to patients who expressed an interest for cessation. Although many GC residents Ask (89% GS versus 100% PC residents; P <.03) and Advise (64% versus 89%; P <.003) new patients about smoking, they did so less frequently than PC residents. GC residents used fewer SCC techniques than did PC residents (3.96 versus 6.00; P <.001) and Arranged fewer follow-up visits for SCC (7% versus 44%; P <.001). Postgraduate year did not correlate with SCC in either GS or PC residents. Residents from both groups perceived time constraints, lack of patient desire, and poor patient compliance to be the main barriers in SCC. CONCLUSION: In this study, many GC residents agreed that physicians were responsible for SCC, but few followed through by arranging SCC follow-up visits compared with their PC resident counterparts. Behavior does not appear to change as residents mature, despite greater exposure to smoking-related diseases. In every dimension of SCC studied, GS residents played a less assertive role when compared with PC residents. GC residents should be more proactive in SCC because the diseases they treat are often related to cigarette smoking.

Expansion rates and outcomes for the 3.0-cm to the 3.9-cm infrarenal abdominal aortic aneurysm.

OBJECTIVE: This study was performed for the determination of the expansion rates and outcomes and for recommendations for the surveillance of the 3.0-cm to 3.9-cm abdominal aortic aneurysm (AAA). DESIGN: The study was observational with data from patients screened with ultrasound scanning for AAA at five Veterans Affairs Medical Centers for enrollment in the Aneurysm Detection and Management Trial. The eligibility requirements included: AAA from 3.0 cm to 3.9 cm in diameter and at least one repeat ultrasound scan more than 90 days after the initial screening. Patients also completed a questionnaire for demographic data and the determination of the presence of risk factors associated with AAA. The study endpoints included: 1, both mean and median expansion rates; 2, moderate expansion (>4 mm/year); 3, no expansion; 4, all causes of death; 5, AAA rupture; 6, expansion to 4 cm or more; 7, expansion to 5.0 cm or more; and 8, operative repair. RESULTS: Ultrasound scan screening results identified 1445 patients with 3.0-cm to 3.9-cm AAAs. Seven hundred ninety men met the ultrasound scan criterion of having at least two ultrasound scan studies during the study period, and these 790 men were used for this study. Mean AAA size was 3.3 cm, with an average follow-up period of 3.89 +/- 1.93 years. The median expansion rate was 0.11 cm/year. Expansion rates were significantly different (P <.001) between 3.0-cm and 3.4-cm cm AAA and 3.5-cm and 3.9-cm AAA. There were no reported AAA ruptures during the study period, although cause of death data were available in only 43% of the patients. Few 3.0-cm to 3.9-cm AAAs expanded to 5.0 cm or more during the study period. The patients with 3.0-cm to 3.9-cm AAAs who underwent operative repair during the study period were younger, had larger initial AAA diameters, and had more rapid expansion rates. CONCLUSION: AAAs of 3.0 cm to 3.9 cm expanded slowly, did not rupture, and rarely had operative repair or expanded to more than 5.0 cm in our study of male patients. Expansion rates and the incidence rate of operative repair are more common in the 3.5-cm to 3.9-cm AAA when compared with the 3.0-cm to 3.4-cm AAA.