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Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms
Cardiovascular Surgery, Vol. 8, No. 1, pp. 18–21, 2000 2000 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd All rights reserved. Printed in Great Britain 0967–2109/00 $20.00
PII: S0967-2109(99)00074-5
www.elsevier.com/locate/cardiosur
Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms T. Busch, H. Sirbu, I. Aleksic, M. Friedrich and H. Dalichau Department of Thoracic and Cardiovascular Surgery, Georg-August-University, Robert-Koch-Str. 40, 37075 Go¨ttingen, Germany Preoperative screening, and interventional and surgical therapy of cardiovascular diseases are of pivotal importance for successful outcome after abdominal aortic aneurysm surgery. In a retrospective study, all patients who underwent surgery for abdominal aortic aneurysm were reevaluated by preoperative diagnostic and therapeutic interventions for cardiovascular disease. Two study periods (1980–1989 and 1990–1996) were compared. Of 603 patients operated upon for abdominal aortic aneurysm between 1980 and 1996, 449 had surgery on an elective basis and 154 as an emergency. Preoperative diagnostic studies for coronary artery disease were performed on elective patients and were positive in 76.8% (1980–1989, 76.1%, 1990–1996, 77.5%). Coronary angiography was performed in 108 patients (29.6%). Medical therapy of coronary artery disease declined by 2.3%, and interventional procedures by 18.8%. In contrast, myocardial revascularization with subsequent aneurysm resection increased by 26.6% and 12 patients (16%) required urgent simultaneous cardiac and aortic surgery. Early mortality after abdominal aortic aneurysm surgery decreased from 4.2 to 2.9%, and the frequency of primary cardiac failure as the cause of death was reduced from 33.3 to 22.2% (P ⬍ 0.05). It was concluded that 42.6% more cardiac surgical procedures were performed before abdominal aortic aneurysm surgery since 1990 compared with the period 1980–1989. In contrast, the number of interventional procedures fell by 18.8%. Surgical therapy of cardiac disease reduces early mortality after elective abdominal aortic aneurysm surgery. 2000 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved
Keywords: abdominal aortic aneurysm, coronary artery disease
Introduction Despite the continuous improvemnet in surgical techniques, vascular prostheses, suture material, perioperative monitoring and intensive-care therapy, elective resection of abdominal aortic aneurysms still carries a considerable risk of perioperative mortality. To a large degree this is caused by the presence of coronary artery disease in this population [1–3]. Coronary artery disease occurs with varying degrees
Correspondence to: Thomas Busch, MD. E-mail: [email protected]
18
of severity in 20–73% of all patients [2–5]. Recent studies have reported a mortality of 1.8–6% after elective surgery for abdominal aortic aneurysm [4– 6]. Cardiac complications accounted for 2.4–13.4% of all complications [2, 5–7] and for 1.8–15% of all fatal outcomes. No consensus exists regarding preoperative cardiological diagnostic tests and cardiovascular therapy. Some surgeons [2, 5] believe intervention to be necessary only in cases of clinical symptoms, and demand diagnostic and therapeutic interventions if the patient has a typical history, ECG-changes or has had previous interventional therapy [3, 4, 7]. The CARDIOVASCULAR SURGERY JANUARY 2000 VOL 8 NO 1
Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms: T. Busch et al.
issue of invasive left heart catheterization as a screening method for the detection of coronary artery disease prior to elective surgery for abdominal aortic aneurysms remains controversial [5]. Undoubtedly, tailored medical therapy is the first line of treatment for each patient. Previous studies have demonstrated that 70% of patients with abdominal aortic aneurysm and known coronary artery disease have significant stenoses. Therefore, these patients should undergo interventional or operative revascularization [3]. Despite the widespread use of PTCA and stent-implantation, operative revascularization seems to have more relevance when one considers that cardiac events are 50% less frequent after coronary bypass surgery than after PTCA [8].
Material and methods All patients who underwent operation for an abdominal aortic aneurysm in the authors’ department between January 1980 and December 1996 were evaluated for in this retrospective study. In order to emphasize the evolution of diagnostic methods and therapeutic approaches, two intervals were defined (interval 1: 1980–1989 and interval 2: 1990–1996). Information about (i) age, sex, clinical diagnosis; (ii) preoperative patient status, cardiac risk factors and diagnostic procedures; (iii) type and method (interventional or surgical) of cardiovascular therapy; (iv) incidence and nature of postoperative complications; and (v) postoperative outcome, were noted. Urgency of the surgical procedure was divided into two categories: (i) elective operations performed on a scheduled basis and (ii) emergency operations performed within a few hours of evaluation. Mortality was defined as death that occurred within 30 days of surgery or beyond that period if the patient had not left the hospital. Statistical analyses All data were entered in a PC (Pentium, Windows 95). Statistical analyses was performed by an Excel 5.0 (Microsoft Inc.) spread sheet and Statistica 5-0 (Stat. Soft) designed for Windows. Univariate testing of data was performed with chi-square or Fischer’s exact test for discrete variables. A probability value P ⬍ 0.05 was considered significant.
Results A total of 603 patients had surgery. Of these, 449 patients (74.5%) underwent elective surgery, and 154 (25.5%) had emergency surgery. Between interval 1 (1980–1989) and 2 (1990–1996) the number of elective operations for abdominal aortic aneurysm CARDIOVASCULAR SURGERY
JANUARY 2000 VOL 8 NO 1
increased by 6.2%, whereas the number of emergency operations fell by 6.1%. Most patients were male with a mean age of 70 years (Table 1). The risk profile for patients with elective surgery showed a 2.5% (n ⫽ 108 versus n ⫽ 239) increase in coronary artery disease, a 7.3% (n ⫽ 80 versus n ⫽ 202) increase in adiposities and 3.1% (n ⫽ 41 versus n ⫽ 101) increase in nicotine abuse between intervals 1 and 2. Other risk factors, such as diabetes (n ⫽ 14 versus n ⫽ 34), hyperlipoproteinemia (n ⫽ 48 versus n ⫽ 98) and hypertension (n ⫽ 82 versus n ⫽ 166), remained constant. A total of 180 elective patients (40%) required echocardiography, stress-ECG, scintigraphy and left heart catheterization for preexisting coronary artery disease (1980–1989: 38 versus 41% from 1990– 1996, NS). The need for coronary angiography was similar during both intervals (23% interval 1 versus 25% interval 2; NS). A total of 109 patients required 111 procedural or operative interventions: 52 patients had triple-, 31 double- and 12 single-vessel disease, 13 patients had left main stem stenosis, two had aortic valvular disease and one had combined coronary artery disease and valvular disease. Comparison of both intervals showed that preoperative tailored medical therapy fell by 2.3% (P ⬍ 0.001) and interventional therapy by means of PTCA or stenting by 19% (NS) (Table 2). In contrast, two-step surgery increased by 27% and simultaneous surgery by 100%. This was because simultaneous surgery for heart disease and abdominal aortic aneurysm was not performed at the authors’ institution before 1991. Twelve patients had simultaneous cardiac and abdominal aortic surgery with a reduced left ventricular ejection fraction ⬍ 30% [9]. Most patients who needed surgical therapy received four bypasses for triple-vessel disease. Among 62 patients who had surgery, 55 received a left internal mammary graft and three patients underwent aortic valve replacement (Table 3). Aneurysms were confined to the infrarenal aorta in 97%, but the incidence of suprarenal aortic aneurysms increased from 1% (n ⫽ 1) to 5% (n ⫽ 14). The incidence of aneurysms extending to the aortic bifurcation only increased from 32% (interval 1) to 60% (interval 2, n ⫽ 46/183;). Aneurysms extending into the iliac arteries were observed less frequently (68% in interval 1 versus 40% in interval 2 (n ⫽ 96/124)). Mean aneurysm diameter at the time of surgery fell by 11.2 mm (71.5 mm during interval 1 versus 60.3 mm in interval 2). Inflammation of the retroperitoneum increased by 1.2%. Concomitant peripheral arterial occlusive disease was present in 30% of patients until 1989 (n ⫽ 44) and 38% of all patients from 1990–1996. Causes of death are shown in Table 4. Early perioperative mortality from cardiac causes was reduced by 1.3% (4.2 versus 2.9% in interval 2). 19
Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms: T. Busch et al. Table 1 Patient data before abdominal aortic aneurysm: resection from 1980 to 1996
1980-1989 1990-1996 Total
Total
Elective
Emergency
Male
Female
Age (years)
201 (33.3%) 402 (66.7%) 603 (100%)
142 (70.6%) 307 (76.4%) 449 (74.5%)
59 (29.4%) 95 (23.3%) 154 (25.5%)
185 (92%) 382 (95%) 567 (93.5%)
16 (8%) 20 (5%) 36 (6.5%)
69 72 70.5
Table 2 Cardiovascular therapy before abdominal aortic aneurysm: resection 1980-1989 Preoperative medical therapy Interventional therapy (PTCA/stent) Two-step surgery Simultaneous surgery
n n n n
⫽ ⫽ ⫽ ⫽
8 (2.5%) 15 (47%) 9 (28%) 0
P
1990-1996
n n n n
⫽ ⫽ ⫽ ⫽
2 21 41 12
(0.2%) (28%) (55%) (16%)
⬍ 0.001 NS ⬍ 0.01 ⬍ 0.025
Table 3 Cardiovascular surgery before abdominal aortic aneurysm–resection (n) AVR AVR ⫹ ACB LIMAB 5 ⫻ ACB 4 ⫻ ACB 3 ⫻ ACB 2 ⫻ ACB 1 ⫻ ACB
2 1 55 10 29 12 5 3
AVR, aortic valve replacement; ACB, aorto coronary bypass; LIMAB, left internal mammaria artery bypass
Table 4 Causes and perioperative mortality after abdominal aortic aneurysm–resection
Hemorrhagic shock Myocardial infarction Respiratory failure Cerebral infarction Septic shock Multi-organ failure Hemostatic disorders Others Total Perioperative mortality Death caused by cardiac disease
1980-1989 (n ⫽ 142)
1990-1996 (n ⫽ 307)
0 2 1 0 1 1 1 0 6 4.20% 33% (n ⫽ 2)
1 2 1 1 2 1 0 1 9 2.90% 22% (n ⫽ 2)
Discussion The increased number of patients that require elective surgery for abdominal aortic aneurysm, together with increasing age, co-morbidity and presence of multiple risk factors mandate a thorough diagnosis and therapy of cardiovascular disease before surgery [10]. As described by other authors [10, 11], we
20
P ⫽ NS P ⬍ 0.025
could demonstrate that more thorough screening for the presence of abdominal aortic aneurysms has led to increasing numbers of operations performed. The number of tube grafts has increased compared with the number of aortobifemoral Y-prostheses. During the study interval, the mean aneurysm diameter at the time of operation became significantly smaller and the number of emergency operations decreased. CARDIOVASCULAR SURGERY JANUARY 2000 VOL 8 NO 1
Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms: T. Busch et al.
Starr et al. [3], as well as other authors [2, 4, 5], describe the incidence of preexisting coronary artery disease to be 70% in patients with abdominal aortic aneurysms. In contrast to the thorough, but invasive screening methods for abdominal aortic aneurysms, studies to detect coronary artery disease are less extensive, but also less invasive. This is the main reason why the complication rate caused by underlying cardiac disease is still up by 15% [6, 7]. In the authors’ patient cohort, cardiac surgical intervention before therapy of abdominal aortic aneurysm has increased by 43% since 1990. The number of interventional therapeutic interventions, i.e. PTCA or stent implantation, has fallen by 19% during over the same time period. This corresponds to findings described by Elmore et al. [8] who observed cardiac events in 56% of patients with previous PTCA at 3 years post-abdominal aortic aneurysm surgery but only in 27% of patients with previous coronary artery bypass grafts. Some authors, such as Fukumura et al. [12], advocate routine coronary angiography before abdominal aortic aneurysm resection. We do not agree with this costly approach, although it has been found that coronary angiography increased the number of cardiac operations before abdominal aortic aneurysm surgery in our own cohort. The same finding was described by Watelet et al. [13]. It is mandatory to establish clinical criteria and precise indications for cardiological diagnostic tests and cardiac surgical therapy as stated by Koskas and Kieffer [11]. This is of pivotal relevance for asymptomatic patients without angina pectoris. It is well known that asymptomatic patients with two- or three-vessel disease have increased perioperative risk [4, 6], which can be minimized by myocardial revascularization before abdominal aortic aneurysm resection [1, 14]. Criteria for invasive testing are as follows: positive history, rhythm disturbances, ECG with signs of myocardial ischemia and overt heart failure [4, 11]. In conclusion, early mortality after abdominal aortic aneurysm surgery can be significantly reduced by primary operative intervention for cardiac disease, regardless of whether it is done consecutively or simultaneously [1, 15, 16]. The relevance of coronary artery disease as a source of peri- and postoperative complications after abdominal aortic aneurysm surgery can be reduced considerably by aggressive surgical intervention for both diseases.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
to abdominal aortic aneurysmectomy. Journal of Cardiovascular Surgery (Torino), 1987, 5, 552–557. ´ Angelo, A. J., Puppala, D., Farber, A. et al., Is preoperative D cardiac evaluation for abdominal aortic aneurysm repair necessary? Journal of Vascular Surgery, 1997, 1, 152–156. Starr, J. E., Hertzer, N. R., Mascha, E. J. et al., Influence of gender on cardiac risk and survival in patients with infrarenal aortic aneurysms. Journal of Vascular Surgery, 1996, 5, 870–880. Langanay, T., Valla, J., Le Du, J. et al., Coronary artery disease in patients with aortic abdominal aneurysm. Apropos of a consecutive series of 172 cases. Arch Mal Coeur Vaiss, 1996, 2, 211–218. Suggs, W. D., Smith, F. B., Weintraub, W. S. et al., Selective screening for coronary artery disease in patients undergoing elective repair of abdominal aortic aneurysms. Journal of Vascular Surgery, 1993, 3, 349–355. Blomberry, P. A., Ferguson, I. A., Rosengarten, D. S. et al., The role of coronary artery disease in complications of abdominal aortic aneurysm surgery. Surgery, 1987, 2, 150–155. Golden, M. A., Whittemore, A. D., Donaldson, M. C. and Mannick, J. A., Selective evaluation and management of coronary artery disease in patients undergoing repair of abdominal aortic aneurysms. A 16-year experience. Annals of Surgery, 1994, 4, 415–420. Elmore, J. R., Hallet, J. W., Gibbons, R. J. et al., Myocardial revascularization before abdominal aortic aneurysmorhaphy: effect of coronary angioplasty. Mayo Clinical Proceedings, 1993, 68, 637–641. Mohr, F. W., Falk, V., Autschbach, R. and Diegeler, A., Onestage surgery of coronary arteries and abdominal aorta in patients with impaired left ventricular function. Circulation, 1995, 91, 379–385. Sayers, R. D., Thompson, M. M., Nasim, A. et al., Surgical management of 671 abdominal aortic aneurysms: A 13-year review from a single centre. European Journal of Endovascular Surgery, 1997, 13, 322–327. Koskas, F. and Kieffer, E., Long-term survival after elective repair of infrarenal abdominal aortic aneurysm: results of a prospective multicentric study. Association for Academic Research in Vascular Surgery (AURC). Annals of Vascular Surgery, 1997, 5, 473–481. Fukumura, Y., Kataoka, Y., Nakai, Y. and Bando, M., Coronary artery disease in patients with abdominal aortic aneurysm. Kyobu Geka, 1990, 43, 364–367. Watelet, J., Papion, H., Soury, P. et al., Coronary assessment and surgery for aortic aneurysm: a pragmatic attitude. Journal of Mal Vasc, 1996, 21A, 1–9. Eisenmann, B., Nicolini, P., Charpentier, A. et al., Evaluation of coronary risk in patients with subrenal abdominal aortic aneurysm. Chirurgie, 1994, 12, 96–99. Autschbach, R., Falk, V., Walther, T. et al., Simultaneous coronary bypass and abdominal aortic surgery in patients with severe coronary disease — indications and results. European Journal of Cardiothoracic Surgery, 1995, 9, 678–683. Young, J. R., Hertzer, N. R. and Beven, E. G., Coronary artery disease in patients with aortic aneurysm: a classification of 302 coronary angiograms and results of surgical treatment. Annals of Vascular Surgery, 1986, 1, 36–42.
Paper accepted 30 July 1999
References 1. Acinapura, A. J., Rose, D. M., Kramer, M. D. et al., Role of coronary angiography and coronary artery bypass surgery prior
CARDIOVASCULAR SURGERY
JANUARY 2000 VOL 8 NO 1
21
PII: S0967-2109(99)00074-5
www.elsevier.com/locate/cardiosur
Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms T. Busch, H. Sirbu, I. Aleksic, M. Friedrich and H. Dalichau Department of Thoracic and Cardiovascular Surgery, Georg-August-University, Robert-Koch-Str. 40, 37075 Go¨ttingen, Germany Preoperative screening, and interventional and surgical therapy of cardiovascular diseases are of pivotal importance for successful outcome after abdominal aortic aneurysm surgery. In a retrospective study, all patients who underwent surgery for abdominal aortic aneurysm were reevaluated by preoperative diagnostic and therapeutic interventions for cardiovascular disease. Two study periods (1980–1989 and 1990–1996) were compared. Of 603 patients operated upon for abdominal aortic aneurysm between 1980 and 1996, 449 had surgery on an elective basis and 154 as an emergency. Preoperative diagnostic studies for coronary artery disease were performed on elective patients and were positive in 76.8% (1980–1989, 76.1%, 1990–1996, 77.5%). Coronary angiography was performed in 108 patients (29.6%). Medical therapy of coronary artery disease declined by 2.3%, and interventional procedures by 18.8%. In contrast, myocardial revascularization with subsequent aneurysm resection increased by 26.6% and 12 patients (16%) required urgent simultaneous cardiac and aortic surgery. Early mortality after abdominal aortic aneurysm surgery decreased from 4.2 to 2.9%, and the frequency of primary cardiac failure as the cause of death was reduced from 33.3 to 22.2% (P ⬍ 0.05). It was concluded that 42.6% more cardiac surgical procedures were performed before abdominal aortic aneurysm surgery since 1990 compared with the period 1980–1989. In contrast, the number of interventional procedures fell by 18.8%. Surgical therapy of cardiac disease reduces early mortality after elective abdominal aortic aneurysm surgery. 2000 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved
Keywords: abdominal aortic aneurysm, coronary artery disease
Introduction Despite the continuous improvemnet in surgical techniques, vascular prostheses, suture material, perioperative monitoring and intensive-care therapy, elective resection of abdominal aortic aneurysms still carries a considerable risk of perioperative mortality. To a large degree this is caused by the presence of coronary artery disease in this population [1–3]. Coronary artery disease occurs with varying degrees
Correspondence to: Thomas Busch, MD. E-mail: [email protected]
18
of severity in 20–73% of all patients [2–5]. Recent studies have reported a mortality of 1.8–6% after elective surgery for abdominal aortic aneurysm [4– 6]. Cardiac complications accounted for 2.4–13.4% of all complications [2, 5–7] and for 1.8–15% of all fatal outcomes. No consensus exists regarding preoperative cardiological diagnostic tests and cardiovascular therapy. Some surgeons [2, 5] believe intervention to be necessary only in cases of clinical symptoms, and demand diagnostic and therapeutic interventions if the patient has a typical history, ECG-changes or has had previous interventional therapy [3, 4, 7]. The CARDIOVASCULAR SURGERY JANUARY 2000 VOL 8 NO 1
Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms: T. Busch et al.
issue of invasive left heart catheterization as a screening method for the detection of coronary artery disease prior to elective surgery for abdominal aortic aneurysms remains controversial [5]. Undoubtedly, tailored medical therapy is the first line of treatment for each patient. Previous studies have demonstrated that 70% of patients with abdominal aortic aneurysm and known coronary artery disease have significant stenoses. Therefore, these patients should undergo interventional or operative revascularization [3]. Despite the widespread use of PTCA and stent-implantation, operative revascularization seems to have more relevance when one considers that cardiac events are 50% less frequent after coronary bypass surgery than after PTCA [8].
Material and methods All patients who underwent operation for an abdominal aortic aneurysm in the authors’ department between January 1980 and December 1996 were evaluated for in this retrospective study. In order to emphasize the evolution of diagnostic methods and therapeutic approaches, two intervals were defined (interval 1: 1980–1989 and interval 2: 1990–1996). Information about (i) age, sex, clinical diagnosis; (ii) preoperative patient status, cardiac risk factors and diagnostic procedures; (iii) type and method (interventional or surgical) of cardiovascular therapy; (iv) incidence and nature of postoperative complications; and (v) postoperative outcome, were noted. Urgency of the surgical procedure was divided into two categories: (i) elective operations performed on a scheduled basis and (ii) emergency operations performed within a few hours of evaluation. Mortality was defined as death that occurred within 30 days of surgery or beyond that period if the patient had not left the hospital. Statistical analyses All data were entered in a PC (Pentium, Windows 95). Statistical analyses was performed by an Excel 5.0 (Microsoft Inc.) spread sheet and Statistica 5-0 (Stat. Soft) designed for Windows. Univariate testing of data was performed with chi-square or Fischer’s exact test for discrete variables. A probability value P ⬍ 0.05 was considered significant.
Results A total of 603 patients had surgery. Of these, 449 patients (74.5%) underwent elective surgery, and 154 (25.5%) had emergency surgery. Between interval 1 (1980–1989) and 2 (1990–1996) the number of elective operations for abdominal aortic aneurysm CARDIOVASCULAR SURGERY
JANUARY 2000 VOL 8 NO 1
increased by 6.2%, whereas the number of emergency operations fell by 6.1%. Most patients were male with a mean age of 70 years (Table 1). The risk profile for patients with elective surgery showed a 2.5% (n ⫽ 108 versus n ⫽ 239) increase in coronary artery disease, a 7.3% (n ⫽ 80 versus n ⫽ 202) increase in adiposities and 3.1% (n ⫽ 41 versus n ⫽ 101) increase in nicotine abuse between intervals 1 and 2. Other risk factors, such as diabetes (n ⫽ 14 versus n ⫽ 34), hyperlipoproteinemia (n ⫽ 48 versus n ⫽ 98) and hypertension (n ⫽ 82 versus n ⫽ 166), remained constant. A total of 180 elective patients (40%) required echocardiography, stress-ECG, scintigraphy and left heart catheterization for preexisting coronary artery disease (1980–1989: 38 versus 41% from 1990– 1996, NS). The need for coronary angiography was similar during both intervals (23% interval 1 versus 25% interval 2; NS). A total of 109 patients required 111 procedural or operative interventions: 52 patients had triple-, 31 double- and 12 single-vessel disease, 13 patients had left main stem stenosis, two had aortic valvular disease and one had combined coronary artery disease and valvular disease. Comparison of both intervals showed that preoperative tailored medical therapy fell by 2.3% (P ⬍ 0.001) and interventional therapy by means of PTCA or stenting by 19% (NS) (Table 2). In contrast, two-step surgery increased by 27% and simultaneous surgery by 100%. This was because simultaneous surgery for heart disease and abdominal aortic aneurysm was not performed at the authors’ institution before 1991. Twelve patients had simultaneous cardiac and abdominal aortic surgery with a reduced left ventricular ejection fraction ⬍ 30% [9]. Most patients who needed surgical therapy received four bypasses for triple-vessel disease. Among 62 patients who had surgery, 55 received a left internal mammary graft and three patients underwent aortic valve replacement (Table 3). Aneurysms were confined to the infrarenal aorta in 97%, but the incidence of suprarenal aortic aneurysms increased from 1% (n ⫽ 1) to 5% (n ⫽ 14). The incidence of aneurysms extending to the aortic bifurcation only increased from 32% (interval 1) to 60% (interval 2, n ⫽ 46/183;). Aneurysms extending into the iliac arteries were observed less frequently (68% in interval 1 versus 40% in interval 2 (n ⫽ 96/124)). Mean aneurysm diameter at the time of surgery fell by 11.2 mm (71.5 mm during interval 1 versus 60.3 mm in interval 2). Inflammation of the retroperitoneum increased by 1.2%. Concomitant peripheral arterial occlusive disease was present in 30% of patients until 1989 (n ⫽ 44) and 38% of all patients from 1990–1996. Causes of death are shown in Table 4. Early perioperative mortality from cardiac causes was reduced by 1.3% (4.2 versus 2.9% in interval 2). 19
Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms: T. Busch et al. Table 1 Patient data before abdominal aortic aneurysm: resection from 1980 to 1996
1980-1989 1990-1996 Total
Total
Elective
Emergency
Male
Female
Age (years)
201 (33.3%) 402 (66.7%) 603 (100%)
142 (70.6%) 307 (76.4%) 449 (74.5%)
59 (29.4%) 95 (23.3%) 154 (25.5%)
185 (92%) 382 (95%) 567 (93.5%)
16 (8%) 20 (5%) 36 (6.5%)
69 72 70.5
Table 2 Cardiovascular therapy before abdominal aortic aneurysm: resection 1980-1989 Preoperative medical therapy Interventional therapy (PTCA/stent) Two-step surgery Simultaneous surgery
n n n n
⫽ ⫽ ⫽ ⫽
8 (2.5%) 15 (47%) 9 (28%) 0
P
1990-1996
n n n n
⫽ ⫽ ⫽ ⫽
2 21 41 12
(0.2%) (28%) (55%) (16%)
⬍ 0.001 NS ⬍ 0.01 ⬍ 0.025
Table 3 Cardiovascular surgery before abdominal aortic aneurysm–resection (n) AVR AVR ⫹ ACB LIMAB 5 ⫻ ACB 4 ⫻ ACB 3 ⫻ ACB 2 ⫻ ACB 1 ⫻ ACB
2 1 55 10 29 12 5 3
AVR, aortic valve replacement; ACB, aorto coronary bypass; LIMAB, left internal mammaria artery bypass
Table 4 Causes and perioperative mortality after abdominal aortic aneurysm–resection
Hemorrhagic shock Myocardial infarction Respiratory failure Cerebral infarction Septic shock Multi-organ failure Hemostatic disorders Others Total Perioperative mortality Death caused by cardiac disease
1980-1989 (n ⫽ 142)
1990-1996 (n ⫽ 307)
0 2 1 0 1 1 1 0 6 4.20% 33% (n ⫽ 2)
1 2 1 1 2 1 0 1 9 2.90% 22% (n ⫽ 2)
Discussion The increased number of patients that require elective surgery for abdominal aortic aneurysm, together with increasing age, co-morbidity and presence of multiple risk factors mandate a thorough diagnosis and therapy of cardiovascular disease before surgery [10]. As described by other authors [10, 11], we
20
P ⫽ NS P ⬍ 0.025
could demonstrate that more thorough screening for the presence of abdominal aortic aneurysms has led to increasing numbers of operations performed. The number of tube grafts has increased compared with the number of aortobifemoral Y-prostheses. During the study interval, the mean aneurysm diameter at the time of operation became significantly smaller and the number of emergency operations decreased. CARDIOVASCULAR SURGERY JANUARY 2000 VOL 8 NO 1
Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms: T. Busch et al.
Starr et al. [3], as well as other authors [2, 4, 5], describe the incidence of preexisting coronary artery disease to be 70% in patients with abdominal aortic aneurysms. In contrast to the thorough, but invasive screening methods for abdominal aortic aneurysms, studies to detect coronary artery disease are less extensive, but also less invasive. This is the main reason why the complication rate caused by underlying cardiac disease is still up by 15% [6, 7]. In the authors’ patient cohort, cardiac surgical intervention before therapy of abdominal aortic aneurysm has increased by 43% since 1990. The number of interventional therapeutic interventions, i.e. PTCA or stent implantation, has fallen by 19% during over the same time period. This corresponds to findings described by Elmore et al. [8] who observed cardiac events in 56% of patients with previous PTCA at 3 years post-abdominal aortic aneurysm surgery but only in 27% of patients with previous coronary artery bypass grafts. Some authors, such as Fukumura et al. [12], advocate routine coronary angiography before abdominal aortic aneurysm resection. We do not agree with this costly approach, although it has been found that coronary angiography increased the number of cardiac operations before abdominal aortic aneurysm surgery in our own cohort. The same finding was described by Watelet et al. [13]. It is mandatory to establish clinical criteria and precise indications for cardiological diagnostic tests and cardiac surgical therapy as stated by Koskas and Kieffer [11]. This is of pivotal relevance for asymptomatic patients without angina pectoris. It is well known that asymptomatic patients with two- or three-vessel disease have increased perioperative risk [4, 6], which can be minimized by myocardial revascularization before abdominal aortic aneurysm resection [1, 14]. Criteria for invasive testing are as follows: positive history, rhythm disturbances, ECG with signs of myocardial ischemia and overt heart failure [4, 11]. In conclusion, early mortality after abdominal aortic aneurysm surgery can be significantly reduced by primary operative intervention for cardiac disease, regardless of whether it is done consecutively or simultaneously [1, 15, 16]. The relevance of coronary artery disease as a source of peri- and postoperative complications after abdominal aortic aneurysm surgery can be reduced considerably by aggressive surgical intervention for both diseases.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
to abdominal aortic aneurysmectomy. Journal of Cardiovascular Surgery (Torino), 1987, 5, 552–557. ´ Angelo, A. J., Puppala, D., Farber, A. et al., Is preoperative D cardiac evaluation for abdominal aortic aneurysm repair necessary? Journal of Vascular Surgery, 1997, 1, 152–156. Starr, J. E., Hertzer, N. R., Mascha, E. J. et al., Influence of gender on cardiac risk and survival in patients with infrarenal aortic aneurysms. Journal of Vascular Surgery, 1996, 5, 870–880. Langanay, T., Valla, J., Le Du, J. et al., Coronary artery disease in patients with aortic abdominal aneurysm. Apropos of a consecutive series of 172 cases. Arch Mal Coeur Vaiss, 1996, 2, 211–218. Suggs, W. D., Smith, F. B., Weintraub, W. S. et al., Selective screening for coronary artery disease in patients undergoing elective repair of abdominal aortic aneurysms. Journal of Vascular Surgery, 1993, 3, 349–355. Blomberry, P. A., Ferguson, I. A., Rosengarten, D. S. et al., The role of coronary artery disease in complications of abdominal aortic aneurysm surgery. Surgery, 1987, 2, 150–155. Golden, M. A., Whittemore, A. D., Donaldson, M. C. and Mannick, J. A., Selective evaluation and management of coronary artery disease in patients undergoing repair of abdominal aortic aneurysms. A 16-year experience. Annals of Surgery, 1994, 4, 415–420. Elmore, J. R., Hallet, J. W., Gibbons, R. J. et al., Myocardial revascularization before abdominal aortic aneurysmorhaphy: effect of coronary angioplasty. Mayo Clinical Proceedings, 1993, 68, 637–641. Mohr, F. W., Falk, V., Autschbach, R. and Diegeler, A., Onestage surgery of coronary arteries and abdominal aorta in patients with impaired left ventricular function. Circulation, 1995, 91, 379–385. Sayers, R. D., Thompson, M. M., Nasim, A. et al., Surgical management of 671 abdominal aortic aneurysms: A 13-year review from a single centre. European Journal of Endovascular Surgery, 1997, 13, 322–327. Koskas, F. and Kieffer, E., Long-term survival after elective repair of infrarenal abdominal aortic aneurysm: results of a prospective multicentric study. Association for Academic Research in Vascular Surgery (AURC). Annals of Vascular Surgery, 1997, 5, 473–481. Fukumura, Y., Kataoka, Y., Nakai, Y. and Bando, M., Coronary artery disease in patients with abdominal aortic aneurysm. Kyobu Geka, 1990, 43, 364–367. Watelet, J., Papion, H., Soury, P. et al., Coronary assessment and surgery for aortic aneurysm: a pragmatic attitude. Journal of Mal Vasc, 1996, 21A, 1–9. Eisenmann, B., Nicolini, P., Charpentier, A. et al., Evaluation of coronary risk in patients with subrenal abdominal aortic aneurysm. Chirurgie, 1994, 12, 96–99. Autschbach, R., Falk, V., Walther, T. et al., Simultaneous coronary bypass and abdominal aortic surgery in patients with severe coronary disease — indications and results. European Journal of Cardiothoracic Surgery, 1995, 9, 678–683. Young, J. R., Hertzer, N. R. and Beven, E. G., Coronary artery disease in patients with aortic aneurysm: a classification of 302 coronary angiograms and results of surgical treatment. Annals of Vascular Surgery, 1986, 1, 36–42.
Paper accepted 30 July 1999
References 1. Acinapura, A. J., Rose, D. M., Kramer, M. D. et al., Role of coronary angiography and coronary artery bypass surgery prior
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