Coronary revascularization before vascular surgery

Patients undergoing vascular surgery are at higher risk for cardiovascular events. Despite published guidelines, the exact approach to pre-operative cardiac evaluation for these patients varies significantly. The report of a VA cooperative study in last week’s NEJM looked at the value of prophylactic coronary-artery revascularization before elective major vascular surgery.

Patients undergoing elective AAA repair or surgery for PVD of the legs were referred for cardiac catheterization if they were felt to be at increased risk for cardiac complications. The exact reasons for referral were variable and included abnormal thallium stress test and high risk based on clinical criteria. Patients were then eligible for randomisation if they had significant coronary disease of at least one vessel and did not have left main disease, aortic stenosis or an EF less than 20%.

510 patients were randomized to either prophylactic revascularization (CABG or angioplasty, at the discretion of the cardiologists) or no revascularization. In the revascularization group, 99 underwent CABG, 141 angioplasty. After mean follow-up of 2.7 years there was no difference in mortality in the two groups (about 22%).

This is the first study to randomize patients to yes-or-no cardiac revascularization prior to vascular surgery. Given the improvement in medical therapy and the peri-operative use of beta-blockers (84% of patients received them in this study), the result is not surprising but is important.

There are some caveats: patients with left main disease were excluded from randomization. Thus, one cannot use these results to say that there is never a need for pre-operative coronary angiography. Furthermore, no-revascularization prior to vascular surgery is not “never” — 8% of patients randomized to this approach underwent coronary revascularization after their elective surgery.