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Indications for myocardial revascularization before endovascular aortic repair
1Institute of CardioVascular Diseases, Hospital Clinic, University of Barcelona, Barcelona, Spain. riambau@meditex.es
Insights
Evaluating coronary risk in patients undergoing endovascular aortic repair (EVAR) is crucial. Pre-operative cardiac assessment helps stratify risk, guiding further testing and intervention to improve outcomes for abdominal aortic aneurysm (AAA) patients.
Area of Science:
- Cardiology
- Vascular Surgery
- Medical Diagnostics
Background:
- Abdominal aortic aneurysm (AAA) repair, particularly endovascular aortic repair (EVAR), carries significant risks of coronary morbidity and mortality.
- A thorough understanding of coronary risk in EVAR patients is essential for optimizing perioperative management and long-term outcomes.
Purpose of the Study:
- To emphasize the importance of pre-operative cardiac evaluation for patients undergoing EVAR.
- To outline a risk stratification strategy for identifying patients who may benefit from further cardiac investigations.
- To guide clinical decision-making regarding coronary revascularization prior to EVAR.
Main Methods:
- Clinical assessment including physical examination, basic laboratory tests, and electrocardiogram (ECG) for initial risk stratification.
- Further diagnostic testing for intermediate-risk patients, including left ventricular function assessment, stress testing (exercise or pharmacological), ambulatory ECG monitoring, and coronary angiography.
- Consideration of advanced imaging like exercise echocardiography or myocardial perfusion imaging for select patients.
Main Results:
- Low-risk patients typically require no further cardiac evaluation.
- High-risk patients generally proceed to coronary angiography.
- Intermediate-risk patients, the largest subgroup, necessitate a tailored approach with additional non-invasive or invasive testing.
Conclusions:
- Comprehensive cardiac assessment is mandatory for EVAR candidates to mitigate perioperative cardiac complications.
- Prognostic high-risk coronary anatomy identified in EVAR patients may warrant prior coronary revascularization to improve long-term outcomes.
- Integrating cardiac risk evaluation into the EVAR pathway can reduce associated morbidity and mortality.
Abstract:
Due to the strong relationship between abdominal aortic aneurysm (AAA) and coronary morbidity and mortality, it seems mandatory to spend some more time investigating about coronary risk of our endovascular aortic repair (EVAR) patients. Physical examination, basic laboratory testing and ECG will allow us to determine whether the surgical risk for a patient is low, moderate or high. In general a patient who is at low risk will not need any further evaluation. Those at who are at high risk usually will undergo coronary angiography. Patients who are at intermediate risk, probably the largest subgroup of patients candidate to EVAR, will often need additional testing like assessment of resting left ventricular function, exercise stress testing, pharmacological stress testing, ambulatory ECG monitoring, and coronary angiography as well as exercise echocardiography or exercise myocardial perfusion imaging should be considered. Patients undergoing an EVAR procedure, who are found to have prognostic high-risk coronary anatomy and in whom long-term outcome would likely be improved by coronary revascularization, should generally undergo revascularization first. In conclusion, we recommend to evaluate the cardiac status of EVAR's patients in order to reduce the most common serious morbidity related to this new therapeutic modality.