Pedal Bypass for Critical Limb Ischemia

Abstract

The role of cardiac risk assessment and preoperative cardiac intervention prior to elective vascular surgery remains controversial. In high cardiac risk patients (severe or unstable angina, recent myocardial infarction, decompensated congestive heart failure [CHF]), the risk of an adverse cardiac event is so great that most would agree that these patients should undergo a preoperative cardiac work-up. In most instances strong consideration in these patients should be given to proceeding directly to coronary arteriography. In patients with low cardiac risk (those with no active cardiac symptoms, and no Eagle risk factors [angina, age >70 years, history of CHF, Q-wave on EKG, diabetes, ventricular ectopy requiring medication]), the adverse cardiac event rate is so low that one can proceed safely to vascular surgery without any additional cardiac testing. The moderate risk group (patients with one or more Eagle risk factors but without severe or recent cardiac symptoms) may potentially benefit from aggressive cardiac intervention. However, the pendulum appears to be swinging toward less preoperative cardiac evaluation in this group as well. Factors that favor a less aggressive approach even in these moderate risk patients include the lower cardiac morbidity and mortality following aortic surgery observed over the last decade, the lack of a good noninvasive cardiac test that is reproducibly predictive of adverse cardiac events, and the absence of data that demonstrate that subjecting a patient to three invasive procedures (coronary arteriography, coronary revascularization, and peripheral vascular operation) is less morbid than proceeding directly to peripheral vascular surgery.