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[Surgery of the aortic arch in coronary patients. 400 surgically treated patients]
J P Cron1, W L Adolph, M Bailly
1Clinique Saint-Gatien, Tours.
Insights
Preventive heart surgery before aorto-iliac surgery is not widely recommended due to low cardiac mortality. However, improved screening for coronary artery disease may increase its use in select patients.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Cardiology
Context:
- Coronary artery disease (CAD) is prevalent in patients undergoing aorto-iliac surgery.
- Assessing pre-operative cardiac risk is crucial for optimizing surgical outcomes.
Purpose:
- To evaluate the efficacy and necessity of preventive aorto-coronary bypass surgery in patients undergoing aorto-iliac procedures.
- To determine optimal strategies for identifying patients who would benefit from pre-operative cardiac intervention.
Summary:
- Out of 400 patients, 11.25% had known coronary disease. Preventive aorto-coronary bypass was performed in 1.75% with no mortality. Overall post-operative mortality was 2.75%, with only 0.25% due to myocardial infarction.
- The study suggests current low rates of cardiac morbidity/mortality do not support broader use of preventive bypass.
- Recommends thallium 201 myocardial scintigraphy with dipyridamole infusion for patients with CAD unable to perform exercise ECG due to claudication to better guide pre-operative coronary arteriography.
Impact:
- The findings suggest that while preventive bypass is safe, its indications should not be broadly extended based on current data.
- Improved pre-operative cardiac risk stratification, particularly using non-invasive imaging, may identify a small subset of patients who could benefit.
- Cancer, exacerbated by alcohol and smoking, was a more significant cause of late mortality (44%) than cardiac events (20%) in this cohort.
Abstract:
Out of 400 consecutive patients who underwent aorto-iliac surgery 45 (11.25 per cent) were known to have coronary disease at the time of the operation. Pre-operative coronary arteriography was carried out in the 11 patients (2.75 per cent) who had unstable or recently worsened angina. Aorto-coronary bypass was performed preventively in 7 patients (1.75 per cent of surgical patients). Mortality from preventive aorto-coronary bypass and secondary aorto-iliac surgery was nil. A study of post-operative mortality (2.75 per cent overall) showed that only one patient (0.25 per cent of surgical patients) died of myocardial infarction. The low rate of post-operative morbidity and mortality of coronary origin therefore does not incline to extend the indications for preventive aorto-coronary bypass. However, it seems desirable to improve the indications for pre-operative coronary arteriography by performing thallium 201 myocardial scintigraphy with dipyridamole infusion in all coronary patients about to undergo aorto-iliac surgery when no exercise electrocardiogram can be obtained because of intermittent claudication. This type of examination will probably broaden the indications for pre-operative coronary arteriography and preventive aorto-coronary bypass, though presumably to a very small extent. Among these 400 patients who underwent aorto-iliac surgery and were all followed up for 2 to 12 years, only a few (0.25 per cent) benefited secondarily from coronary surgery, no doubt because the physiological age of that population was often too high. In fact, these patients were mainly at risk of cancer aggravated by both alcohol and smoking, for in this study, and rather in contrast with most publications, cancer was responsible for 44 per cent of secondary deaths, i.e. more than twice the percentage (20 per cent) of secondary deaths of cardiac origin.