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Is preoperative cardiac evaluation for abdominal aortic aneurysm repair necessary?
A J D'Angelo1, D Puppala, A Farber
1Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA.
Insights
Routine cardiac testing before abdominal aortic aneurysm (AAA) repair is not necessary. This study found no significant difference in outcomes for patients undergoing AAA repair with or without cardiac workup, suggesting intraoperative management is key.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Anesthesiology
Background:
- A significant percentage of patients with abdominal aortic aneurysms (AAA) have concomitant coronary artery disease (CAD).
- Aggressive cardiac workup is often recommended before AAA repair, but its clinical utility is debated.
- This study challenges the necessity of pre-operative cardiac testing for AAA repair.
Purpose of the Study:
- To evaluate the safety and efficacy of elective abdominal aortic aneurysm (AAA) repair without routine pre-operative cardiac testing.
- To compare outcomes between patients who underwent AAA repair with and without prior cardiac workup.
Main Methods:
- A retrospective review of 113 consecutive elective AAA repairs was conducted.
- Patients were divided into two groups: Group A (electrocardiogram only) and Group B (additional cardiac testing).
- Outcomes including myocardial infarction, other complications, and mortality were compared between groups.
Main Results:
- No statistically significant differences in demographics or comorbidities were observed between groups, except for higher rates of prior myocardial infarction and congestive heart failure in Group B.
- Surgical outcomes, including blood loss, transfusion needs, operative times, and postoperative complications, were similar between groups.
- There was no significant difference in myocardial infarction rates (0% in Group A vs. 5.1% in Group B), with only one cardiac-related death in the overall series.
Conclusions:
- Pre-operative cardiac workup for abdominal aortic aneurysm (AAA) repair provides limited additional information and does not significantly impact clinical outcomes.
- Elective AAA repair can be safely performed without extensive cardiac testing.
- Intraoperative hemodynamic management appears to be a more critical factor in determining patient outcomes after AAA repair.
Purpose:
It is reported that 25% to 50% of patients with abdominal aortic aneurysms (AAA) have severe coronary artery disease (CAD) and should undergo an aggressive cardiac workup before AAA repair. In contrast, it has been our policy that patients referred for AAA repairs undergo no cardiac testing before surgery.
Methods:
This report reviews the last 113 consecutive patients who underwent elective AAA repair by the senior author using this policy. Seventy-four patients (group A) had only an electrocardiogram before surgery. The remaining 39 patients (group B) were referred having already had additional testing that included a thallium stress test (n = 20), echocardiogram (n = 18), multiple gated acquisition (MUGA) scan (n = 3), cardiac catheterization (n = 8), or some combination of these.
Results:
There was no statistical difference between group A and group B with regard to age, sex, tobacco use or history of coronary artery disease, diabetes mellitus, stroke (CVA), hypertension, peripheral vascular disease, or chronic obstructive pulmonary disease. Group B more commonly had a history of myocardial infarction (41% vs 19%, p < 0.03) and congestive heart failure (23% vs 7%, p < 0.03). During surgery there was no significant differences in blood loss, transfusion requirements, or operative times. There were no myocardial infarctions in group A and two (5.1%) in group B, which was not significantly different. Other complications, such as CVA, renal failure, pulmonary failure, pneumonia, wound infection, and hemorrhage, were not significantly different between the two groups. Postoperative hospital stay was not significantly different. There were three deaths in the entire series (2.7%), and only one in group B was cardiac-related in a patient with known end-stage cardiac disease and a symptomatic 8 cm AAA.
Conclusions:
These data indicate that most patients with AAA can safely undergo repair with no cardiac workup and that cardiac workup before AAA repair contributes little information that impacts on treatment or final clinical outcome. We conclude that cardiac testing in preparation for AAA repair is not usually necessary and that intraoperative hemodynamic management may be the most important variable in determining outcome.