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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
[Perioperaive evaluation and management in vascular surgery especially for arteriosclerosis obliterans]
Yoshinori Inoue1, Takehisa Iwai
1Department of Vascular and Applied Surgery, Tokyo Medical and Dental University Graduate School, Tokyo, Japan.
Insights
Patients undergoing vascular surgery for arteriosclerosis obliterans (ASO) face high cardiac event risks. This study suggests targeted noninvasive testing and specific interventions can reduce perioperative ischemic heart disease (IHD).
Area of Science:
- Cardiology
- Vascular Surgery
- Anesthesiology
Context:
- Perioperative cardiac events are a significant cause of mortality in patients undergoing vascular surgery for arteriosclerosis obliterans (ASO).
- Current guidelines, including the ACC/AHA recommendations and the revised cardiac risk index (CRI), are used for risk stratification and management.
- The majority of ASO patients are elderly and inactive, necessitating comprehensive noninvasive cardiac testing.
Purpose:
- To evaluate the effectiveness of risk stratification tools and perioperative management strategies for reducing cardiac events in ASO patients.
- To determine optimal noninvasive testing protocols and the utility of diagnostic tools like electrocardiograms (ECGs) and cardiac biomarkers.
- To assess the efficacy of pharmacological interventions such as beta-blockers and alpha-agonists in preventing perioperative ischemic heart disease (IHD).
Summary:
- ACC/AHA guidelines classify most vascular procedures (excluding carotid endarterectomy) as high-risk. A stepwise Bayesian strategy indicated noninvasive testing for nearly all ASO patients.
- Patients with a revised CRI < 1 had low prevalence (2.5%) and incidence (1.3%) of IHD, suggesting noninvasive testing may be most beneficial for those with revised CRI > 2.
- ECGs at baseline and post-surgery are cost-effective for IHD diagnosis. Cardiac biomarkers are reserved for high-risk individuals or those with clinical/ECG evidence of myocardial infarction (MI).
- Beta-blockers and alpha-agonists demonstrated effectiveness in reducing perioperative IHD incidence.
Impact:
- This research provides evidence-based recommendations for optimizing cardiac risk assessment and management in vascular surgery patients with ASO.
- Implementing these strategies can potentially decrease perioperative cardiac morbidity and mortality, improving patient outcomes.
- The findings support a more tailored approach to noninvasive cardiac testing and intervention, enhancing the cost-effectiveness of care.
Abstract:
Perioperative cardiac event is relatively high in vascular surgery for arteriosclerosis obliterans (ASO), which is a major cause of postoperative death. ACC/AHA guideline and revised cardiac risk index (CRI) were advocated to assess risk factor stratification and to manage risk reduction. ACC/AHA guideline categorized all vascular procedures except carotid endarterectomy as high risk. Because almost all patients with ASO were aged and/or inactive, noninvasive testing was necessary in almost all patients by the stepwise bayesian strategy. Patients with revised CRI less than 1 point dominated about three fourths of all patients, whose prevalence and incidence of ischemic heart disease (IHD) were 2.5% and 1.3%, respectively. It seemed appropriate to apply noninvasive testing only for patients with revised CRI more than 2 points, and high risk indicated coronary angiography. Electrocardigrams obtained at baseline, immediately, and on the first 2 days after surgery appear to be cost-effective to diagnose IHD. Use of cardiac biomarkers was reserved for patients at high risk and those with clinical, or ECG evidence of myocardial infarction (MI). Beta-blockers or alpha-agonists were effective to reduce incidence of perioperative IHD. Although even optimal preoperative assessment and perioperative management, some patients will have perioperative MI.
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