Perioperative clinical variables and long-term survival following vascular surgery

Abstract

Cardiovascular disease is the leading cause of death in patients with peripheral arterial disease (PAD). Coronary artery disease (CAD) is highly prevalent, and often times coexist, in patients with PAD. The management of patients with PAD that requires a high-risk vascular surgical procedure for intermittent claudication, critical limb ischemia or expanding abdominal aortic aneurysm requires risk stratification with the revised cardiac risk index, optimization of medical therapies, and limited use of cardiac imaging prior to surgery. Preventive revascularization in patients with stable CAD, with the sole intention to mitigate the risk of cardiac complications in the peri-operative period, is not effective and may be associated with significant bleeding and thrombotic risks, in particular if stents are used. A strategy of universal use of cardiac troponins in the perioperative period for active surveillance of myocardial ischemia may be more reasonable and cost-effective than the current standard of care of widespread use of cardiac imaging prior to high-risk surgery. An elevated cardiac troponin after vascular surgery is predictive of longterm mortality risk. Medical therapies such as aspirin and statins are recommended for patients with postoperative myocardial ischemia. Ongoing trials are assessing the role of novel anticoagulants. Additional research is needed to define the role of cardiac imaging and invasive angiography in this population.

Cardiovascular Risk Evaluation in Patients with Critical Leg Ischemia before Vascular Surgery

“…An isolated peak cardiac biomarker elevation (preferably Tn) with or without correlation with ischemia may be the most sensitive tool to detect perioperative ischemic events that are clinically important [29]. A peak postoperative TnT (>0.02 ng/ml) measured within the first 3 days after surgery is the strongest predictor of 30 days mortality and explained 41.8% of the deaths in population [30].…”

“…US evaluation is useful in defining the group of patients with low CV risk, in which can be performed with relative safety the revascularization of the limb by interventional/surgery procedures. these tests do not provide information about cerebrovascular ischemic risk, derived from cervical arterial lesions, almost equally founded as coronary involvement in vascular surgery patients [7,29]. Clinical judgment is important in assessing the balance between the relative urgency of identified cardiac and noncardiac surgery problems.…”

“…A relatively small proportion of surgical patients require urgent preoperative treatment of cardiac conditions: congestive HF, life-threatening arrhythmias or acute coronary syndrome (ACS) (recent MI with significant evidence of ischemic risk or unstable, severe AP). However, there are situations in which the surgical situation with an important vital risk imposes the operative decision, even under an incomplete cardiac evaluation [7,29].…”

Myocardial infarction after carotid endarterectomy

“…Для больных со-судистого профиля это осложнение приводит к увеличе-нию длительности госпитализации и ухудшению резуль-татов лечения [4]. Следовательно, оценка дооперацион-ных факторов риска развития ИМ -актуальный вопрос выбора метода лечения.…”