682 Symposium: Coexistent Cardiac and Peripheral Vascular Disease

)'ournal of VASCULAR

SURGERY

Routine coronary angiography in patients undergoing surgery for abdominal aortic aneurysm and lower extremity occlusive disease Edwin G. Beven, M.D., Cleveland, Ohio

Coronary artery disease (CAD) is prevalent among patients with peripheral arterial problems and accounts for approximately 50% of all perioperative and late mortality statistics after operations for ab- dominal aortic aneurysm (AAA) and peripheral ar- terial reconstructions. 1-3 Hertzer 4 and Diehl et al., s reporting on the experience at The Cleveland Clinic observed that myocardial infarction accounted for 45% of perioperative deaths occurring after AAA resection and for 67% after aortoiliac reconstruc- tion for lower extremity ischemia, whereas long- term follow-up revealed that cardiac complications caused from 38% to 55% of all late deaths. More importantly, statistically significant differences were observed in early mortality between patients with no clinical indication of CAD (2.9%) and those with overt CAD (9.6%). Late survival (5-year) was similarly affected, 82% for those with no clinical evidence of CAD and 67% for those with clinical indication of CAD by conventional clinical criteria.

Direct myocardial revascularization procedures by coronary artery bypass grafts (CABGs), on the other hand, are associated with a perioperative mor- tality rate of only 2% and the 5-year postoperative survival is better than 90%. 6,7 Furthermore, there is indication that patients with previous myocardial re- vascularization have fewer cardiac complications after subsequent vascular or other major operations. From 1974 through 1978, 557 patients underwent abdom- inal aortic reconstruction for AAA or for occlusive disease of the aortoiliac segment at The Cleveland Clinic. The perioperative mortality rate was 5.1% for those patients with intact aneurysms, 2.3% for those with aortoiliac occlusive disease, whereas 87 patients who had incidental previous CABGs survived?

From the Department of Vascular Surgery, The Cleveland Clinic Foundation.

Presented at the combined breakfast program of the Society for Vascular Surgery and the International Society for Cardiovas- cular Surgery, North American Chapter, Baltimore, Md., June 8, 1985.

Reprint requests: Edwin G. Beven, M.D., Department of Vascular Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44106.

Considering the eroding influence that CAD has on early and late survival for patients with peripheral vascular disease, it seemed appropriate to document the presence and severity of coronary lesions on pa- tients who were considered to be candidates for vas- cular reconstruction. Therefore, coronary arteriog- raphy was recommended to all patients admitted f~" investigation to the Department of Vascular S ~ e r y at The Cleveland Clinic. 8 When severe correctable CAD was documcnted, direct myocardial revascu- larization was performed before the planned periph- eral reconstruction. This series comprises 1000 pa- tients investigated at The Cleveland Clinic from 1978 through 1982. 8

RESULTS OF CORONARY ANGIOGRAPHY

Only 8% of patients had normal coronary arter- ies, and in another 32%, CAD was limited only to a mild to moderate degree. Advanced but compen- sated coronary lesions were defined in 29% of pa- tients. Severe, surgically correctable CAD was ob- served in 25%, whereas severe, inoperable CAD was documented in 6% of patients. Severe CAD was documented in 36% of patients with AAA and in 28% of those with occlusive disease of the lower e~ tremities.

CLINICAL CARDIAC STATUS

The relationship between the coronary anglo- graphic findings and the clinical cardiac evaluation is shown in Table I. A normal coronary system or mild to moderate CAD was observed in 63% of patients with no clinical indication of CAD and in 22% of those who were suspected to have CAD by conven- tional criteria. Severe, surgically correctable CAD was demonstrated in 14% of patients without indi- cations of CAD and in 34% of those in whom CAD was suspected, whereas inoperablc CAD was present in 1% and 10% of these groups, respectively. Of those patients with suspected CAD on clinical grounds, coronary angiography confirmed that 44% either deserved CABG or were inoperable from a cardiac standpoint.

Volume 3 Number 4 April 1986 Symposium: Coexistent Cardiac and Peripheral Vascular Disease 6 8 3

Tab.e I. Angiographic classification of coronary artery disease according to clinical indications

Clinical coronary disease

No indication Suspected

No. % No. %

Normal coronary arteries Mild to moderate CAD Advanced but compensated CAD Severe, correctable CAD Severe, inoperable CAD

64 14 21 4 218 49 99 18

97 22 192 34 63 14 188 34

4 1 54 10

SURGICAL RESULTS On the basis of the findings obtained by cardiac

catheterization, 226 patients underwent cardiac op- erations, of which 212 were myocardial revascular- L tions. CABG was performed in 70 (28%) of 250 patio[ ~s with AAA, 70 (18%) of 381 with lower extremity occlusive disease, and in 63 (21%) of 295 patients with cerebrovascular disease.

A total of 1066 operations for correction of pri- mary peripheral vascular diagnosis were performed for 796 patients in this study. Myocardial revascu- larization was performed in 130 patients as a prelim- inary procedure. The operative mortality rate for CABG was 5.2% and for peripheral vascular oper- ations, 2%. Only one death (0.8%) occurred after peripheral vascular reconstruction in the group of 130 patients who had preliminary myocardial revas- cularization. Another two patients (0.9%) died of aneurysm rupture after cardiac operation. The overall cardiac and peripheral vascular operative mortality rate was 3.9% for patients with primary diagnosis of AAA, 2.4% for patients with lower extremity isch- emia, and 1.8% for those with cerebrovascular 1: "0blems.

DISCOSSION The results of this investigation indicate that ap-

proximately 30% of all patients who are candidates for peripheral vascular reconstruction demonstrate severe CAD; most patients have disease that is po- tentially correctable by myocardial revascularization. Since randomization was not part of this study, one cannot conclude that the acceptable surgical mortal- ity obtained was modified by the selective use of preliminary myocardial revascularization. However, one has the distinct impression that the vascular re- construction can be performed with a greater margin of safety.

Since the completion of this study, coronary ar- teriography has been used selectively. It is recom- mended to all patients with clinical evidence of CAD, • ~incc this group of patients had the highest yield of

severe CAD. However, for those patients with no indication of CAD by clinical criteria, noninvasive testing by stress electrocardiography or radionuclide myocardial scanning is recommended, followed by coronary arteriography for those patients with in- dications of myocardial ischemia. For those patients with severe, inoperable CAD, safer management can be planned by modification of standard operations with a "lesser" operation, by use of special precau- tions during the anesthetic management or by non- operative treatment.

Finally, it is anticipated that late survival statistics will be enhanced by the use of myocardial revascu- larization for the group 0fpatients with documented severe CAD and for whom previous follow-up stud- ies have indicated poor long-term survival.

SUMMARY

Between 1978 and 1982, 1000 patients under consideration for peripheral vascular reconstruction underwent coronary angiography. Normal coronary arteries were found in 8%; mild to moderate coro- nary artery disease (CAD), in 32%; advanced but compensated CAD, in 29%; severe correctable CAD, in 25%; and inoperable CAD, in 6%. Severe cor- rectable CAD was demonstrated in 14% of patients who had no indications of CAD on clinical criteria. Patients with severe correctable CAD were advised to undergo myocardial revascularization before the vascular operation. Under this protocol, a total of 1292 cardiac and peripheral vascular reconstructions were performed with an overall mortality rate of 2.6% (5.2% for myocardial revascularization and 2% for vascular operation). Only one death (0.8%) oc- curred after peripheral vascular reconstruction in 130 patients who had preliminary myocardial revascular- ization. These results indicate that approximately 30% of all patients who require vascular reconstruc- tion have severe, but surgically correctable, CAD and that preliminary myocardial revascularization appears to add a margin of safety to the subsequent vascular operation.

684 Symposium: Coexistent Cardiac and Peripheral Vascular Disease

Journal of VASCULAR

SURGERY

REFERENCES

1. Thompson JE, HoLlier LH, Patman RD, Persson AV. Surgical management of abdominal aortic aneurysms: Factors influenc- ing mortality and morbidity--a 20-year experience. Ann Surg 1975; 181:654-61.

2. Brown OW, Hollier LH, Pairolero PC, Kazmier RJ, McCready RA. Abdominal aortic aneurysm and coronary artery disease: A reassessment. Arch Surg 1981; 116:1484-7.

3. Crawford ES, Bomberger RA, Glaeser DH, Saleh SA, Russell WL. Aortoiliac occlusive disease: Factors influencing survival and fimction following reconstructive operation over a twenty- five year period. Surgery 1981; 90:1055-67.

4. Hertzer NR. Fatal myocardial infarction following peripheral vascular operations. A study of 951 patients followed 6 to 11 years postoperatively. Cleve Clin Q 1982; 49:1-11.

5. Diehl JT, Cali RF, Hertzer NR, Beven EG. Complicaf~s of abdominal aortic reconstruction. Ann Surg 1983; 197:49-56.

6. Loop FD, Cosgrove DM, Lyde BW, Thurer RL, Simpfen- dorfer C, Taylor PC, Proudfit WL. An 11-year evolution of coronary arterial surgery (1967-1978). Ann Surg 1979; 190:444-55.

7. Loop FD, Cosgrove DM, Lytle BW, Golding LR. Life ex- pectancy after coronary artery surgery. Am J Surg 1981; 141:665.

8. Hertzer NR, Beven EG, Young JR, O'Hara PJ, Ruschhaupt WF, Graor RA, deWolfe VG, Maljovec LC. Coronary artery disease in peripheral vascular patients. A classification of 1000 coronary angiograms and results of surgical management. Ann Surg I984; 199:223-33.

Major stroke after coronary artery bypass surgery: Changing magnitude of the problem Timothy J. Gardner, M.D., Peter J. Horneffer, M.D., Teri A. Manolio, M.D., Steven J. Hoff, B.A., and Thomas A. Pearson, M.D., Ph.D., Baltimore, Md.

Despite continued decreases in operative mortal- ity rates for patients undergoing coronary artery by- pass grafting (CABG), 1'2 the occurrence of major ncurologic injuries associated with this operation ap- pears to be increasing, s A review was undertaken of the CABG experience at this hospital over the past 11 years to examinc the pattern of major central neu- rologic complications occurring after coronary by- pass surgery. In addition, a case-control study was carried out in which multiple potential risk factors for stroke were examined in the CABG patients.

PATIENT POPULATION

During the 11-year period from 1974 through 1984, 3816 patients had isolated CABG procedures at The Johns Hopkins Hospital. Excluded from this report are patients who had CABG in combination with any other surgical procedure, including valve replacement, ventricular aneurysm resection, or ca-

From the Division of Cardiac Surgery and Department of Med- icine, The Johns Hopkins Medical Institutions.

Presented at the combined breakfast program of the Society for Vascular Surgery and the International Society for Cardiovas- cular Surgery, North American Chapter, Baltimore, Md., June 8, 1985.

Reprint requests: Timothy J. Gardner, M.D., Division of Cardiac Surgery, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD 21205.

rotid endarterectomy. Men comprised just over 80% of the population and the mean age of the CABG group rose steadily from 51.9 years in 1974 to 59.4 years in 1984. Furthermore, nearly 55% of the pa- tients were 60 years or older at the time of operation and 15% of the group were in their 70s or 80s when undergoing CABG.

The entire group of 3816 patients was analyzed with respect to age at operation, outcome of surgery, and the occurrence of any major ncurologic i n j ~ ~ in association with the operation. All pat ier~who had a eercbrovascular accident (CVA) in association with their CABG procedure were identified, with stroke defined as the development of a new focal neurologic deficit or deficits confirmed by CT scans.

In addition to the general evaluation of the entire CABG population, a case-control study was per- formed in an attempt to define possible risk factors for CVA in this coronary bypass population. Two control patients were identified for each patient in the group who suffered a stroke, with the control patients selected by choosing the two non-CVA pa- tients who immediately preceded each stroke patient during the review period. Included among the vari- ables examined in the case-control study were the patient's age, sex, date of operation, whether there was a medical history of hypertension, diabetes reel-