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Validation of selective cardiac evaluation prior to aortic aneurysm repair
1Department of Surgery, University of California Medical Center, VA Medical Center, San Diego, USA.
Insights
Selective coronary artery disease evaluation before abdominal aortic aneurysm (AAA) repair is safe and effective. This approach identifies patients needing intervention, leading to excellent perioperative and long-term outcomes in AAA surgery patients.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Interventional Cardiology
Background:
- Coronary artery disease (CAD) is prevalent in patients undergoing abdominal aortic aneurysm (AAA) repair.
- Preoperative cardiac evaluation strategies aim to mitigate perioperative risks.
Purpose of the Study:
- To assess perioperative and long-term morbidity in patients undergoing AAA repair with selective CAD evaluation.
- To determine the efficacy of a tiered approach to cardiac risk stratification.
Main Methods:
- A case series of 189 patients undergoing AAA repair between 1989 and 1996.
- Patients were stratified into three groups based on cardiac risk and history.
- Interventions included stress testing, coronary angiography, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass (CAB) as indicated.
Main Results:
- Overall perioperative mortality was 1.1%, with 1% nonfatal myocardial infarctions (MIs), primarily in higher-risk groups without intervention.
- Seventeen percent of patients experienced arrhythmias or congestive heart failure, with a higher incidence in those with recent revascularization.
- Long-term survival was 87.9% at 3 years and 69.7% at 5 years.
Conclusions:
- Selective preoperative CAD screening is effective in managing patients undergoing AAA repair.
- This strategy achieves favorable perioperative and late outcomes, with 35.7% of patients having undergone prior revascularization.
Objective:
To evaluate perioperative and long-term morbidity in patients undergoing selective evaluation of coronary artery disease prior to abdominal aortic aneurysm (AAA) repair.
Design:
Case series.
Setting:
University and Veterans' Administration medical centers.
Patients:
One hundred eighty-nine consecutive patients undergoing AAA repair between January 1989 and September 1996 were selectively evaluated for coronary artery disease and assigned to 1 of 3 groups: group 1, no abnormal cardiac history, normal electrocardiogram; group 2, minimal symptoms, history of myocardial infarction (MI), older than 70 years, diabetes mellitus, or congestive heart failure; or group 3, severe or unstable angina, ventricular dysfunction.
Interventions:
Group 1 patients proceeded to AAA repair without further workup. Group 2 patients underwent pharmacologic or exercise stress testing followed by coronary angiography and intervention as required. Group 3 patients went directly to coronary angiography and intervention as needed.
Main Outcome Measures:
Perioperative MI, arrhythmias, or death. Long-term follow-up measures included MI and death.
Results:
Adequate documentation was available on 171 patients. Twenty-four patients (14%) were in group 1. Of 136 patients (79.5%) in group 2, coronary angiography was performed in 36 (26%), followed by percutaneous transluminal coronary angioplasty (PTCA) in 9 (7%) and coronary artery bypass (CAB) in 5 (4%). Of 11 patients in group 3, 3 (27%) each received PTCA and CAB. Remote CAB or PTCA had been performed in 32 (19%) and 12 (7%) patients, respectively. Two perioperative deaths (1.1%) occurred in the 189 patients, one due to MI in a group 2 patient. There were 2 (1%) nonfatal MIs, both in group 2 patients who had no preoperative intervention. Arrhythmias and/or congestive heart failure occurred in 17 (9%) cases, 7 (39%) having had recent coronary revascularization (P = .001). By univariate analysis, only preoperative renal dysfunction predicted perioperative complications (P = .03) Overall survival by lifetable analysis was 87.9% and 69.7% at 3 and 5 years, respectively.
Conclusion:
Coronary artery disease is common in patients undergoing AAA repair, with 35.7% having preoperative coronary revascularization at some point. Selective preoperative coronary artery disease screening achieves excellent perioperative and late results in this population.