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Global revascularization: the role of the cardiologist
Christopher J White1, Stephen R Ramee, Tyrone J Collins
1Department of Cardiology, Ochsner Medical Institutions, New Orleans, Louisiana, USA.
Insights
Cardiologists should adopt a global approach to peripheral vascular diseases due to atherosclerosis being a systemic condition. This comprehensive care improves management of coronary artery disease and related complications.
Area of Science:
- Cardiology
- Vascular Medicine
- Interventional Cardiology
Background:
- Atherosclerosis is a systemic disease affecting both coronary and peripheral vasculature.
- Coronary artery disease (CAD) is a leading cause of mortality in peripheral vascular disease (PVD) patients.
- PVD complicates the management of angina pectoris and congestive heart failure.
Purpose of the Study:
- To advocate for a global approach by cardiologists to patients with PVD.
- To highlight key areas of interest for cardiologists in PVD: iliac, renal, subclavian, and carotid arteries.
- To emphasize the importance of specialized training and a multidisciplinary team for interventional cardiologists performing peripheral angioplasty.
Main Methods:
- Review of the systemic nature of atherosclerosis and its impact on cardiovascular health.
- Identification of specific peripheral arterial territories relevant to cardiology.
- Discussion of transferable skills from coronary angioplasty to peripheral interventions.
- Emphasis on essential knowledge including natural history, patient/lesion selection, and alternative treatments.
- Advocacy for comprehensive training and team-based care involving vascular surgeons.
Main Results:
- Coronary and peripheral vascular diseases frequently coexist in the same patient.
- PVD significantly increases morbidity and mortality, primarily due to CAD.
- Cardiologists' clinical expertise enhances procedural decision-making and patient care in PVD.
- Transferable skills from coronary angioplasty can be applied to peripheral interventions with appropriate training.
Conclusions:
- Cardiologists must adopt a global perspective for managing patients with PVD.
- Specialized training and collaboration are crucial for interventional cardiologists performing peripheral angioplasty.
- A clinician-cardiologist's long-term patient relationship optimizes procedural indications, timing, and risk-benefit assessment.
- Integrated cardiology care is appropriate given the high incidence of CAD in patients with atherosclerotic PVD.
Abstract:
There are compelling reasons for cardiologists to undertake a more global approach to patients with peripheral vascular diseases: atherosclerosis is a 'systemic' disease frequently causing both coronary and peripheral vascular problems in the same patient; coronary artery disease is the most common cause of morbidity and mortality in patients with peripheral vascular disease; and peripheral vascular disease negatively impacts the management of angina pectoris and congestive heart failure. There are four major areas of special interest to the cardiologist: (1) iliac arteries (vascular access), (2) renal arteries (hypertension and volume overload), (3) subclavian arteries (coronary steal with a left internal mammary artery [LIMA] graft), and (4) carotid arteries (stroke). Technical skills necessary to perform coronary angioplasty are transferable to the peripheral vasculature. However, an understanding of the natural history of peripheral disease, patient and lesion selection criteria, and knowledge of other treatment alternatives are essential to performing these procedures safely and effectively. Appropriate preparation and training, and a team approach, including an experienced vascular surgeon, are both desirable and necessary before interventional cardiologists who are inexperienced in the treatment of peripheral vascular disease attempt percutaneous peripheral angioplasty. There are inherent advantages for patients when the cardiologist performing the procedure is also a clinician. Judgments regarding the indications, timing, and risk/benefit ratio of procedures are enhanced by a long-term relationship between physician and patient. Finally, in view of the increased incidence of coronary artery disease in patients with atherosclerotic peripheral vascular disease, the participation of a cardiologist in their care seems appropriate.