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Atheroembolization in cardiac surgery. The need for preoperative diagnosis
P H Kolh1, D F Torchiana, M J Buckley
1Cardiac Surgical Unit, Massachusetts General Hospital, Boston, USA.
Insights
Atheroembolism after cardiac surgery is linked to older age and pre-existing conditions like hypertension. This complication significantly increases patient mortality and healthcare costs, necessitating better preoperative risk identification.
Area of Science:
- Cardiovascular Surgery
- Vascular Medicine
- Critical Care Medicine
Background:
- Atheroembolization is a serious complication of cardiac surgery, leading to stroke, organ failure, and death.
- Preoperative identification of high-risk patients is crucial for mitigating these risks.
Purpose of the Study:
- To identify preoperative risk factors for atheroemboli.
- To evaluate the postoperative outcomes of patients who developed atheroembolic syndrome.
Main Methods:
- Retrospective review of 5486 cardiac surgery patients from 1990-1994.
- Identified 107 patients (1.9%) who developed atheroembolic syndrome.
Main Results:
- Patients with atheroemboli were older and had higher rates of hypertension, cerebrovascular disease, and aortoiliac disease.
- Complications included renal insufficiency (35%) and peripheral emboli (12%).
- Significantly longer ICU/hospital stays and higher costs were observed; 48 patients died, and only 2 were discharged home.
Conclusions:
- Atheroembolization has severe medical and economic impacts.
- Diffuse aortic disease requires systemic, not local, management strategies.
- Preoperative identification of extensive aortic atheromatous disease is essential.
Background:
Atheroembolization is a recognized complication of cardiac surgical procedures, and has been implicated in postoperative stroke, renal failure, multiorgan failure, and death. Preoperative identification of patients at risk for developing atheroemboli is essential. The aim of this study was to determine preoperative risk factors for atheroemboli and to assess the postoperative course of the patients who developed atheroembolic syndrome.
Methods:
A retrospective record review was conducted. From 1/1990 to 12/1994 5486 patients underwent coronary artery bypass grafting (CABG), valve operations, or other cardiac surgical procedures at Massachusetts General Hospital. Of this population, 107 patients (1.9%) developed atheroembolic syndrome.
Results:
Patients who develop atheroemboli were older, with an increased incidence (p < 0.01) of hypertension, cerebrovascular disease, and aortoiliac disease. Many had a complicated course after catheterization, with renal insufficiency (35%) and evidence of peripheral emboli (12%). Average Intensive Care Unit stay, hospital stay, and hospital cost of these patients were respectively 16.8 days, 48.4 days, and $88,000, compared to 1.5 days, 9.6 days and $23,000 for a concurrent population undergoing CABG surgery. Of these 107 patients only 2 were discharged home, the others either died (48 patients, or 25% of all cardiac surgical deaths during this period), or went to rehabilitation or chronic hospital facilities. Twenty-seven autopsies were performed and invariably showed a diffusely diseased aorta, with calcification, mural thrombus, and ulceration.
Conclusions:
Atheroembolization during cardiac surgical procedures has profound medical and economic consequences. Because of the diffuse nature of aortic disease, measures approaching the disease as a local process are likely to be unsuccessful. Appropriate evaluation would ideally identify patients with extensive aortic atheromatous disease, prior to rather than during surgery.