Myocardial injury after endovascular revascularization in critical limb ischemia predicts 1-year mortality: a prospective observational cohort study

Abstract

BackgroundPatients with critical limb ischemia (CLI) are at increased risk of cardiovascular complications and mortality. To determine (1) incidence of myocardial injury following endovascular revascularization, and (2) relationship between myocardial injury with 1-year mortality and major adverse cardiovascular events (MACE; i.e., composite of myocardial infarction, stroke, and death).Methods and resultsSingle-center, prospective cohort study of CLI patients ≥ 45 years of age, who underwent endovascular revascularization with overnight hospitalization. High-sensitive troponins T (hsTnTs) were measured on admission, 3–6 h after endovascular revascularization and the subsequent morning. Myocardial injury after endovascular revascularization was defined as an hsTnT ≥ 14 ng/L with a relative increase ≥ 30% from the baseline value. We also evaluated other myocardial injury hsTnT thresholds (i.e., ≥ 30, ≥ 40, ≥ 60, and ≥ 80 ng/L). 239 consecutive patients (56% male, mean age 71.5 ± 10.1 years) were included; one patient was lost to follow-up. At 1 year, there were 34 deaths (14.2%), and 48 MACE (20.5%). Myocardial injury with the hsTnT threshold of 14 ng/L and relative increase by ≥ 30% from the baseline level occurred in 61 patients (25.5%). Myocardial injury was independently associated with 1-year mortality ([aHR], 2.44; 95% CI 1.18–5.06, for hsTnT ≥ 14 ng/L to aHR, 3.34; 95% CI 1.29–8.65 for hsTnT ≥ 80 ng/L). Myocardial injury was also independently associated with 1-year MACE ([AOR] 2.89; 95% CI 1.41–5.92 for hsTnT ≥ 14 ng/L to AOR, 6.69; 95% CI 2.17–20.68 for hsTnT ≥ 80 ng/L). 85.2% patients who had myocardial injury did not have ischemic clinical symptoms or electrocardiography changes. In sensitive analysis with exclusion of symptomatic patients that developed myocardial injury for the hsTnT ≥ 14 ng/L threshold, both the 1-year mortality (aHR: 2.19; CI 1.02–4.68; p = 0.04), and 1-year MACE (OR 2.25; CI 1.06–4.77; p = 0.036) remained significant.ConclusionsMyocardial injury is common following endovascular revascularization for CLI and associated with the risk of 1-year mortality and MACE.

Incidence and predictors of myocardial and kidney injury following endovascular aortic repair: a retrospective cohort study

“…16,31 Also, in contrast to the findings reported by Saratzis et al, we found that both decreased preoperative eGFR level and length of surgery were independent predictors of AKI. 14 We hypothesize that the lower prevalence of perioperative AKI observed in our study group is likely explained by a difference in baseline characteristics between study cohorts and a larger sample size in our study (i.e., 267 patients in our cohort compared with 149 and 87 patients in cohorts by Saratzis et al and Pirgakis et al, respectively). It is also possible that patients whose postoperative creatinine level was not measured contributed to a lower incidence of AKI, although our sensitivity analyses did not suggest that these variables were missing not at random and that these patients would differ from the rest of the population.…”

“…Szczeklik et al also described that myocardial injury is frequent in patients undergoing endovascular revascularization for critical limb ischemia, with a 25.5% incidence of myocardial injury after surgery. 14 Until now, little was known about the prevalence of myocardial injury in patients undergoing EVAR. In a small cohort study of 30 patients who underwent EVAR and had routine troponin T (TnT) measured 24 hr after their procedure, Davies et al showed that five patients (16%) experienced myocardial injury defined as a significant elevation of TnT levels and only one had chest pain with ischemic ECG changes.…”

“…Also, patients who suffered a myocardial injury required more red blood cell transfusions. Patients with myocardial injury also had a prolonged median [IQR] length of hospital stay than patients without myocardial injury (8 [4][5][6][7][8][9][10][11][12][13][14][15] days vs 5 [4][5][6][7][8][9] days, respectively; P \ 0.001). In multivariate analysis, age, RCRI score C 3, ASA physical status IV, duration of surgery, and perioperative drop in hemoglobin significantly increased the risk of myocardial injury ( Table 3).…”

“…The majority of patients with postoperative AKI (24/25, 96%) met the stage 1 AKIN criteria (i.e., increase in serum creatinine C 27 lmolÁL-1 or C 1.5-fold compared with baseline level) and 4% (1/25) met the stage 3 AKIN criterion for AKI (i.e., increase in serum creatinine [ three-fold compared with baseline level). In general, patients who developed AKI had lower preoperative eGFR, [7][8][9][10][11][12][13][14][15][16][17] days vs 5 [4][5][6][7][8][9][10] days, respectively; P = 0.01). In multivariate analysis, length of surgery and preoperative eGFR were associated with AKI occurrence (Table 4).…”

“…6,[8][9][10][11][12][13] Recent reports revealed that myocardial injury after vascular surgery can affect between 19 and 25% of patients, while AKI can develop in up to 19% of those who underwent endovascular aortic repair. 10,[13][14][15][16] The majority of patients with postoperative myocardial injury and AKI do not experience clinical ischemic symptoms; therefore, in the absence of routine postoperative troponin and creatinine surveillance, myocardial and kidney injuries are frequently missed in clinical practice. 10,17,18 Considering the importance of postoperative acute renal and myocardial injuries and the limited evidence regarding these events in EVAR patients, we undertook this study to determine the incidence and predictors of postoperative AKI and myocardial injury in this population.…”