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Comparative early and late cardiac morbidity among patients requiring different vascular surgery procedures
G J L'Italien1, R P Cambria, B S Cutler
1Department of Surgery, Massachusetts General Hospital, Boston 02114, USA.
Insights
Vascular surgery type does not significantly impact cardiac risk; instead, patient comorbidities like coronary artery disease (CAD) are the primary drivers of perioperative and long-term events. Careful patient assessment is crucial regardless of the procedure.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Cardiac Risk Assessment
Background:
- Coronary artery disease (CAD) evaluation is vital for patients undergoing vascular surgery.
- The independent risk contribution of specific vascular procedures versus CAD determinants is unclear.
Purpose of the Study:
- To quantify the relative impact of vascular procedures and CAD markers on perioperative and long-term cardiac risk.
Main Methods:
- 547 patients undergoing aortic, infrainguinal, or carotid vascular surgery were evaluated.
- Dipyridamole thallium testing and clinical assessments were performed.
- Perioperative and late cardiac risks (myocardial infarction) were compared across procedures, adjusting for comorbidities.
Main Results:
- Infrainguinal procedures showed higher initial perioperative MI risk (13%) than aortic/carotid (6%), but this difference became insignificant after risk factor adjustment.
- Long-term event rates were significantly higher for infrainguinal (74% event-free survival) and carotid (78%) compared to aortic (90%) procedures.
- After adjustment, infrainguinal procedures' threefold late event risk reduced to insignificant levels.
Conclusions:
- Observed cardiac risk differences in vascular surgery are mainly due to patient CAD risk factors, not the procedure type.
- Patient cardiac and diabetic status require careful consideration irrespective of the planned vascular surgery.
Purpose:
The evaluation of coronary artery disease (CAD) in patients undergoing vascular surgery can provide information with respect to perioperative and long-term risk for CAD-related events. However, the extent to which the required surgical procedure itself imparts additional risk beyond that dictated by the presence of CAD determinants remains in question. The purpose of this study was to quantify the relative contributions of specific vascular procedures and CAD markers on perioperative and long-term cardiac risk.
Methods:
The study cohort comprised 547 patients undergoing vascular surgery from two medical centers who underwent clinical evaluation, dipyridamole thallium testing, and either aortic (n = 321), infrainguinal (n = 177), or carotid (n = 49) vascular surgery between 1984 and 1991. Perioperative and late cardiac risk of fatal or nonfatal myocardial infarction (MI) was compared for the three procedures before and after adjustment for the influence of comorbid factors. These adjusted estimates may be regarded as the component of risk because of type of surgery.
Results:
Perioperative MI occurred in 6% of patients undergoing aortic and carotid artery surgery, and in 13% of patients undergoing infrainguinal procedures (p = 0.019). Significant (p < 0.05) predictors of MI were history of angina, fixed and reversible dipyridamole thallium defects, and ischemic ST depression during testing. Although patients undergoing infrainguinal procedures exhibited more than twice the risk for perioperative MI compared with patients undergoing aortic surgery (relative risk: 2.4[1.2 to 4.5, p = 0.008]), this value was reduced to insignificant levels (1.6[0.8 to 3.2, p = 0.189]) after adjustment for comorbid factors. There was little change in comparative risk between carotid artery and aortic procedures before (1.0[0.3 to 3.6, p = 0.95]) or after (0.6[0.2 to 2.3, p = 0.4]) covariate adjustment. The 4-year cumulative event-free survival rate was 90% +/- 2% for aortic, 74% +/- 5% for infrainguinal, and 78% +/- 7% for carotid artery procedures (p = 0.0001). Predictors of late MI included history of angina, congestive heart failure, diabetes, fixed dipyridamole thallium defects, and perioperative MI. Patients undergoing infrainguinal procedures exhibited a threefold greater risk for late events compared with patients undergoing aortic procedures (relative risk: 3.0[1.8 to 5.1, p = 0.005]), but this value was reduced to 1.3(0.8 to 2.3, p = 0.32) after adjustment. Long-term risk among patients undergoing carotid artery surgery was less dramatically altered by risk factor adjustment.
Conclusion:
In current practice, among patients referred for dipyridamole testing before operation, observed differences in cardiac risk of vascular surgery procedures may be primarily attributable to readily identifiable CAD risk factors rather than to the specific type of vascular surgery. Thus the cardiac and diabetic status of patients should be given careful consideration whenever possible, regardless of surgical procedure to be performed.