Diagnosis of silent coronary ischemia with selective coronary revascularization might improve 2-year survival of patients with critical limb-threatening ischemia

Abstract

Background: Patients with critical limb-threatening ischemia (CLTI) have had poor long-term survival after lower extremity revascularization owing to coexistent coronary artery disease. A new cardiac diagnostic test, coronary computed tomography-derived fractional flow reserve (FFR CT ), can identify patients with ischemia-producing coronary stenosis who might benefit from coronary revascularization. We sought to determine whether the diagnosis of silent coronary ischemia before limb salvage surgery with selective postoperative coronary revascularization can reduce the incidence of adverse cardiac events and improve the survival of patients with CLTI compared with standard care.Methods: Patients with CLTI and no cardiac history or symptoms who had undergone preoperative testing to detect silent coronary ischemia with selective postoperative coronary revascularization (group I) were compared with patients with standard preoperative cardiac clearance and no elective postoperative coronary revascularization (group II). Both groups received guideline-directed medical care. Lesion-specific coronary ischemia in group I was defined as FFR CT of #0.80 distal to a stenosis, with severe ischemia defined as FFR CT of #0.75. The endpoints included all-cause death, cardiovascular (CV) death, myocardial infarction (MI), major adverse CV events (i.MACE; CV death, MI, unplanned coronary revascularization, stroke) through 2 years of follow-up.Results: Groups I (n ¼ 111) and II (n ¼ 120) were similar in age (66 6 9 vs 66 6 7 years), gender (78% vs 83% men), comorbidities, and surgery performed. In group I, unsuspected, silent coronary ischemia was found in 71 of 103 patients (69%), with severe ischemia in 58% and left main coronary ischemia in 8%. Elective postoperative coronary revascularization was performed in 47 of 71 patients with silent ischemia (66%). In group II, the status of silent coronary ischemia was unknown. The median follow-up was >2 years for both groups. The 2-year outcomes for groups I and II were as follows:

Coronary revascularization of patients with silent coronary ischemia may reduce the risk of myocardial infarction and cardiovascular death after carotid endarterectomy

“…18,25 Similarly, it has been shown that lower-extremity revascularization can be performed safely despite preoperative FFR CT evidence of silent coronary ischemia with long-term survival benefit with postoperative coronary revascularization. 16,17 The 80% reduction in the risk of cardiac death and the 84% reduction in the risk of MI associated with elective coronary revascularization in our study are not surprising given the extent and severity of asymptomatic coronary ischemia in the FFR CT -guided group. More than half of patients (57%) had one or more ischemia-producing coronary lesions, and 44% of patients had severe coronary ischemia with FFR CT values below 0.75.…”

“…15 This strategy of selective coronary revascularization after recovery from surgery, in addition to optimal medical therapy (OMT), resulted in fewer cardiovascular deaths and MIs and improved 2-and 3-year survival compared with standard cardiac evaluation and care. 16,17 We performed a similar study in patients undergoing CEA. Preoperative cardiac evaluation of patients with no known CAD using CTA and FFR CT revealed a high prevalence of asymptomatic coronary ischemia and demonstrated the potential value of FFR CT -guided coronary revascularization in reducing the risk of adverse cardiac events.…”

Major Lower Limb Amputations and Amputees in an Aging Population in Southwest Finland 2007–2017

“…Patients with CLTI have multiple comorbidities, and operation risks are elevated. 24 , 25 Moreover, young CLTI patients have a high prevalence of DM, poor glycemic control, coronary artery disease, smoking, renal insufficiency, and high WIfI stage. 26 On the other hand, non-ambulatory associated conditions such as a higher BMI are less common in younger CLTI patients compared to older age groups, 26 which therefore enables an active revascularization strategy to be used.…”