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Pro: Combined coronary and vascular surgery is better than separate procedures
PRO AND CON P a u l G. Barash, M D Section Editor
Pro: Combined Coronary and Vascular Surgery Is Better Than Separate Procedures Barry A. Finegan, MB, FRCPC and Ibrahim Kashkari, MB, FRCPC
DVANCES IN the management of acute coronary occlusion have reduced the incidence of completed myocardial infarction and hence overall mortality from coronary artery disease (CAD). In patients suffering from acute coronary occlusion perioperatively, however, thrombolytic therapy and emergency angioplasty are usually contraindicated and care entails observation and treatment of complications, rather than active intervention to revascularize the myocardium. Given this reality, it is not surprising that the 30% to 50% mortality rate associated with a perioperative myocardial infarction has not significantly altered over the years. 1 The pathophysiology of fatal perioperative myocardial infarctions appears to be similar to that thought to be responsible for nonoperative myocardial infarction, ie, plaque disruption and dynamic obstruction of coronary vessels. There is a high incidence of multivessel disease and left main disease in patients suffering fatal perioperative myocardial infarctions.2 Although peripheral vascular disease is not synonymous with CAD, there is a clear association between these two disease entities. Hertzer et al 3 prospectively assessed coronary artery anatomy by angiography in 1,000 patients presenting for peripheral vascular reconstruction. This series included patients presenting for abdominal aortic aneurysm (AAA) resection, carotid endarterectomy, and lower extremity arterial bypass surgery. Severe correctable CAD, defined as stenosis greater than 70% in one or more coronary arteries serving unimpaired myocardium and representing an immediate and foreseeable risk for myocardial infarction, was detected in 25% of the study population. In patients with a clinical history suggesting preexisting CAD, the incidence of severe correctable disease was 34%. In the absence of a clinical history, the occurrence of severe correctable CAD was 14%. Ashton et al,4 in a study of more than 1,400 men undergoing noncardiac surgery, found that elective vascular surgery was an independent risk factor (fourfold increase) for perioperative myocardial infarction. These data underscore the need for rigorous preoperative assessment of patients presenting for vascular surgery and for individualized risk assessment of this patient population.
A
CAD AND AAA RESECTION
The importance of aggressive surgical treatment for an AAA greater than 6 cm in diameter was first shown more than 30 years ago. 5 Surgical intervention resulted in a 5-year survival rate of 53%, whereas non-surgically treated patients had a 6% 5-year survival. In this early series, the importance of CAD in the etiology of both early (47% of cases) and late (38% of cases) mortality was identified.5 Perioperative myocardial infarction remains the leading cause of early death in patients undergoing AAA repair. 6 Appropriate and selective coronary revascularization of patients with severe surgically correctable CAD reduces both perioperative and late mortality in this patient population.
In the Cleveland Clinic series, 7 the overall operative mortality rate for patients who underwent coronary artery bypass grafting (CABG) and AAA repair procedures was 4%, with a cumulative 5-year survival rate of 75%. In the subset of patients with uncorrected coronary disease, the cumulative 5-year survival rate was 29%. Similar data apply to the octogenarian patient population, in whom the cumulative 5-year survival was 75% in patients who had CABG or angioplasty before AAA resection, compared with a 30% five-year survival rate for all other patients. 8 In conclusion, in the patient with severe surgically correctable symptomatic CAD scheduled for AAA repair, the issue is not whether coronary revascularization should be performed, but rather when it should occur. TIMING OF CABG AND AAA SURGERY
The principal structural proteins of the aorta are elastin and collagen. In aneurysmal disease, elastin content is markedly reduced and collagen turnover is increased) Elevated levels of urokinase-type plasminogen activator (nPA), which converts plasminogen into its active form plasmin, are found in human aneurysmal aortic tissue. 1° uPA content and activity are increased after trauma or surgical stress. These findings offer a plausible but unproven explanation of reports citing the occurrence of an increased rate of aneurysmal rupture after unrelated surgical procedures H or CABG performed in anticipation of AAA repair.12 In the latter report,12 the influence of the timing of CABG on long-term survival in patients scheduled to have AAA repair was retrospectively assessed. In 23 patients with asymptomatic AAA greater than 5 cm in diameter, those who underwent AAA repair simultaneously or within 2 weeks of CABG suffered no mortality. In nine patients scheduled to undergo AAA repair more than 2 weeks after CABG, three died of rupture of their AAA before the scheduled repair operation. In another series of 70 patients who underwent CABG before AAA resection as part of a two-stage procedure, two patients (2.9%) died as a consequence of a ruptured AAA while in the hospital recovering from their CABG surgery. 13 These data would tend to support the concept of a combined CABG and AAA repair surgery, at least in patients with severe CAD and symptomatic AAA. 14 It is also apparent that considerable cost savings can be realized by performing combined surgery. 15The
From the Department of Anaesthesia, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada. Address reprint requests to Barry A. Finegan, MB, FRCPC, Department of Anaesthesia, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada T6G 2H7. Copyright © 1998 by W.B. Saunders Company 1053-0770/98/1202-002258.00/0 Key words: coronary artery bypass, carotid endartectomy/risk factors, abdominal aortic aneurysm/risk factors
Journal of Cardiothoracic and Vascular Anesthesia, Vo112,No 2 (April), 1998:pp 225-227
225
226
FINEGAN AND KASHKARI
Table 1, Published Results of Combined CABG and A A A Procedures Study
No. Patients
Mortality (%)
Whittemore et a128(1980) David TM (1984) Ruby et al TM (1985) Reul et a127(1986) Emery et al2s (1988) Westaby et a129(1992) Vicaretti et al3° (1994) Black and Desai31 (1995) Mohr et al is (1995)
2 4 6 11 2 8 15 3 25
0 0 0 0 0 25 6.7 0 12
equate to identify patients at risk of adverse cardiovascular outcomes following surgery. 19 CABG AND CAROTID STENOSIS
published results of combined CABG and AAA surgical procedures are shown in Table I. The most recent data constitute the largest series in high-risk patients. 16 Of 25 patients who underwent combined CABG and AAA repair, all had severe CAD with either unstable angina and/or left ventricular ejection fraction (LVEF) <35%. Ten patients had an LVEF <20%. In addition to CABG and AAA, three patients had an aortic valve replacement, two had carotid endarterectomies, and three had renal artery revascularization. The surgical procedure involved CABG followed by AAA surgery. Patients were not weaned from bypass until the distal aortic anastomosis was completed. Three patients died (overall 30-day mortality, 12%), one from an intraoperative myocardial infarction, one from heparin-induced thrombocytopenia, and one from multiorgan failure. Ten patients suffered postoperative complications, the most serious of which were a completed stroke in a patient who had an aortic valve replacement and severe lower limb ischemia requiring amputation in a patient with severe peripheral vascular disease. Actuarial 1-year survival rate was 88%. These data suggest that patients previously considered inoperable may be candidates for combined CABG and AAA repair surgery. COMBINED CABG AND VASCULAR SURGERY FOR AORTIC OCCLUSIVE DISEASE
The very limited data available suggest that there is little benefit to this combination of procedures except in extreme circumstances. Extracorporeal circulation may further impair limb perfusion, and vein harvesting and wound repair in an ischemic limb may be very difficult. 16 CAROTID SURGERY AND CAD
Angiographically normal coronary anatomy was detected in only 9% of 295 patients presenting for carotid endarterectomy, whereas 26% were found to have severe correctable disease. 3 Short-term and long-term mortality in carotid endarterectomy patients is increased in patients with preexisting or occult CAD. 17,t8Patients undergoing carotid surgery should be screened for CAD and simple noninvasive investigations may be ad-
In a retrospective study of 1,779 patients who underwent preoperative carotid duplex scanning before CABG and valve surgery, carotid stenosis of >50% luminal diameter was detected in 263 patients. 2° This finding was the most powerful predictor of postoperative stroke (odds ratio, 6.01). Eighty-one patients has occlusions between 75% and 99% of luminal diameter. D'Agostino et a121 prospectively assessed the incidence and risk factors for stroke in 1,835 patients undergoing first-time CABG: although carotid stenosis >50% was a risk factor in this population, age, perioperative cardiac functional status, and procedure-related factors were also important. Thus, in patients scheduled for elective CABG, a not insignificant number may require carotid endarterectomy. TIMING OF CABG AND CAROTID ARTERY SURGERY
Should CABG and carotid endarterectomy be performed as combined or staged procedures? This issue has been addressed in only one randomized controlled trial,22 in which 129 patients with unstable cardiac disease were prospectively randomized to receive either combined operations or CABG alone, with carotid endarterectomy delayed until the patient had recovered from the cardiac procedure. The composite stroke rate for patients undergoing combined procedures was 2.8%, whereas that for patients in whom delayed carotid endartrectomy was performed within 2 weeks was 14%. Postponing the carotid procedure for a longer interval reduced the risk of staged procedures to that equivalent to the combined group (2.2%). Observational data23 lend further support to the performance of combined procedm-es in which significant surgically correctable cardiovascular and cerebrovascular disease coexist. Recent cost analysis data also support the safety and economic benefit of combined relative to separate staged CABG and carotid endarterectomy procedures. 24 Surgical skill is an essential element in patient outcome after carotid surgery. Participants in the pivotal Asymptomatic Carotid Atherosclerosis Study were subject to prestudy audit of their last 50 cases and were refused participation if their neurologic morbidity and mortality in asymptomatic patients was greater than 3%. 25 This important factor should be considered both in the interpretation of the literature and in advising patients of the risks of combined procedures. CONCLUSION CAD is a common finding in patients scheduled for vascular surgical procedures. Carotid disease is not uncommonly detected in patients scheduled for CABG. Given the availability of skilled anesthesia and surgical personnel, combined AAA and CABG surgery and combined carotid and CABG surgery are safe and cost effective.
REFERENCES
1. Ashton CM: Perioperative myocardial infarction with noncardiac surgery.AmJMed Sci 308:41-48, 1994 2. Dawood MM, Gutpa DK, Southern J, et al: Pathology of fatal perioperative myocardial infarction: Implications regarding pathophysiology and prevention. IntJ Cardio157:37-44, 1996
3. Hertzer NR, Beven EG, Young JR, et al: Coronary artery disease in peripheral vascular patients. A classification of 1000 coronary angiograms and results of surgical management. Ann Surg 199:223233, 1984 4. Ashton CM, Petersen NJ, Wray NP, et al: The incidence of
PRO AND CON
perioperative myocardial infarction in men undergoing noncardiac surgery. Ann Int Med 118:504-510, 1993 5. Szilagyi DE, Smith RF, DeRusso FJ, et al: Contribution of abdominal aortic aneurysmectomy to prolongation of life. Ann Surg 164:678-699, 1966 6. Chen JC, Hildebrand HD, Salvian AJ, et al: Predictors of death in nouruptured and ruptured abdominal aortic aneurysms. J Vasc Surg 24:614-23, 1996 7. Hertzer NR, Young JR, Beven EG, et al: Late results of coronary bypass in patients with infrarenal aortic aneurysms. The Cleveland Clinic Study. Ann Surg 205:360-367, 1987 8. O'Hara PJ, Hertzer NR, Krajewski LP, et al: Ten-year experience with abdominal aortic aneurysm repair in octogenarians: Early results and late outcome. J Vasc Surg 21:830-838, 1995 9. Thompson RW: Basic science of abdominal aortic aneurysms: Emerging therapeutic strategies for an unresolved clinical problem. Curr Opin Cardiol 11:504-518, 1996 10. Shireman PK, McCarthy WJ, Pearce WH, et al: Elevations of tissue-type plasminogen activator and differential expression of urokinase-type plasminogen activator in diseased aorta. J Vasc Surg 25:157164, 1997 11. Swanson RJ, Littooy FN, Hunt TK, Stoney RJ: Laparotomy as a precipitating factor in the rupture of intra-abdominal aneurysms. Arch Surg 115:299-304, 1980 12. Blackbourue LH, Tribble CG, Langenburg SE, et al: Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization. Ann Snrg 219:693-698, 1994 13. Hertzer NR, Young JR, Beven EG, et al: Late results of coronary bypass in patients with peripheral vascular disease. II. Five-year survival according to sex, hypertension, and diabetes. Cleve Clin J Med 54:15-23, 1987 14. Ruby ST, Whittemore AD, Couch NP, et al: Coronary artery disease in patients requiring abdominal aortic anem'ysm repair. Selective use of a combined operation. Ann Surg 201:758-764, 1985 15. David TE: Combined cardiac and abdominal aortic surgery. Circulation 72:II18-21, 1985 16. Molar FW, Falk V, Autschbach R, et al: One-stage surgery of coronary arteries and abdominal aorta in patients with impaired left ventricular function. Circulation 91:379-385, 1995 17. Hertzer NR, Lees CD: Fatal myocardial infarction following carotid endarterectomy: Three hundred thirty-five patients followed 6-11 years after operation. Ann Surg 194:212-218, 1981
227
18. Hertzer NR, Arison R: Cumulative stroke and survival ten years after carotid endarterectomy. J Vasc Surg 2:661-668, 1985 19. Urbinati S, Di Pasquale G, Andreoli A, et al: Preoperative noninvasive coronary risk stratification in candidates for carotid endarterectomy. Stroke 25:2022-2027, 1994 20. Ricotta JJ, Faggioli GL, Castilone A, Hassett JM: Risk factors for stroke after cardiac surgery: Buffalo Cardiac-Cerebral Study Group. J Vasc Surg 21:359-64, 1995 21. D'Agostino RS, Svensson LG, Neumann DJ, et al: Screening carotid ultrasonography and risk factors for stroke in coronary artery surgery patients. Ann Thorac Surg 62:1714-1723, 1996 22. Hertzer NR, Loop FD, Beven EG, et al: Surgical staging for simultaneous coronary and carotid disease: A study including prospective randomization. J Vasc Surg 9:455-463, 1989 23. Akins CW, Moncure AC, Daggett WM, et al: Safety and efficacy of concomitant carotid and coronary artery operations. Ann Thorac Surg 60:311-318, 1995 24. Daily PO, Freeman RK, Dembitsky WP, et al: Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting. J Thorac Cardiovasc Surg 111:1185-1193, 1996 25. Moore WS, Young B, Baker WH, et al: Surgical results: A justification of the surgeon selection process for the ACAS trial. The ACAS Investigators. J Vasc Surg 23:323-328, 1996 26. Whittemore AD, Clowes AW, Hechtman HB, Mannick JA: Aortic anenrysm repair. Reduced operative mortality associated with maintenance of optimal cardiac performance. Ann Surg 192:414-421, 1980 27. Reul GJ Jr, Cooley DA, Duncan JM, et al: The effect of coronary bypass on the outcome of peripheral vascular operations in 1093 patients. J Vasc Surg 3:788-798, 1986 28. Emery RW, Ott RA, Bernhard V, et al: Surgical approach to combined coronary revascularization and abdominal aortic aneurysmectomy. J Cardiovasc Surg (Torino) 29:143-145, 1988 29. Westaby S, Parry A, Grebenik CR, et al: Combined cardiac and abdominal aortic aneurysm operations. The dual operation on cardiopulmonary bypass. J Thorac Cardiovasc Surg 104:990-995, 1992 30. Vicaretti M, Fletcher JP, Richardson A, et al: Combined coronary artery bypass grafting and abdominal aortic aneurysm repair. Cardiovasc Surg 2:340-343, 1994 31. Black JJ, Desai JB: Combined coronary artery bypass surgery and abdominal aortic aneurysm repair. J R Soc Med 88:350P-352P, 1995
Pro: Combined Coronary and Vascular Surgery Is Better Than Separate Procedures Barry A. Finegan, MB, FRCPC and Ibrahim Kashkari, MB, FRCPC
DVANCES IN the management of acute coronary occlusion have reduced the incidence of completed myocardial infarction and hence overall mortality from coronary artery disease (CAD). In patients suffering from acute coronary occlusion perioperatively, however, thrombolytic therapy and emergency angioplasty are usually contraindicated and care entails observation and treatment of complications, rather than active intervention to revascularize the myocardium. Given this reality, it is not surprising that the 30% to 50% mortality rate associated with a perioperative myocardial infarction has not significantly altered over the years. 1 The pathophysiology of fatal perioperative myocardial infarctions appears to be similar to that thought to be responsible for nonoperative myocardial infarction, ie, plaque disruption and dynamic obstruction of coronary vessels. There is a high incidence of multivessel disease and left main disease in patients suffering fatal perioperative myocardial infarctions.2 Although peripheral vascular disease is not synonymous with CAD, there is a clear association between these two disease entities. Hertzer et al 3 prospectively assessed coronary artery anatomy by angiography in 1,000 patients presenting for peripheral vascular reconstruction. This series included patients presenting for abdominal aortic aneurysm (AAA) resection, carotid endarterectomy, and lower extremity arterial bypass surgery. Severe correctable CAD, defined as stenosis greater than 70% in one or more coronary arteries serving unimpaired myocardium and representing an immediate and foreseeable risk for myocardial infarction, was detected in 25% of the study population. In patients with a clinical history suggesting preexisting CAD, the incidence of severe correctable disease was 34%. In the absence of a clinical history, the occurrence of severe correctable CAD was 14%. Ashton et al,4 in a study of more than 1,400 men undergoing noncardiac surgery, found that elective vascular surgery was an independent risk factor (fourfold increase) for perioperative myocardial infarction. These data underscore the need for rigorous preoperative assessment of patients presenting for vascular surgery and for individualized risk assessment of this patient population.
A
CAD AND AAA RESECTION
The importance of aggressive surgical treatment for an AAA greater than 6 cm in diameter was first shown more than 30 years ago. 5 Surgical intervention resulted in a 5-year survival rate of 53%, whereas non-surgically treated patients had a 6% 5-year survival. In this early series, the importance of CAD in the etiology of both early (47% of cases) and late (38% of cases) mortality was identified.5 Perioperative myocardial infarction remains the leading cause of early death in patients undergoing AAA repair. 6 Appropriate and selective coronary revascularization of patients with severe surgically correctable CAD reduces both perioperative and late mortality in this patient population.
In the Cleveland Clinic series, 7 the overall operative mortality rate for patients who underwent coronary artery bypass grafting (CABG) and AAA repair procedures was 4%, with a cumulative 5-year survival rate of 75%. In the subset of patients with uncorrected coronary disease, the cumulative 5-year survival rate was 29%. Similar data apply to the octogenarian patient population, in whom the cumulative 5-year survival was 75% in patients who had CABG or angioplasty before AAA resection, compared with a 30% five-year survival rate for all other patients. 8 In conclusion, in the patient with severe surgically correctable symptomatic CAD scheduled for AAA repair, the issue is not whether coronary revascularization should be performed, but rather when it should occur. TIMING OF CABG AND AAA SURGERY
The principal structural proteins of the aorta are elastin and collagen. In aneurysmal disease, elastin content is markedly reduced and collagen turnover is increased) Elevated levels of urokinase-type plasminogen activator (nPA), which converts plasminogen into its active form plasmin, are found in human aneurysmal aortic tissue. 1° uPA content and activity are increased after trauma or surgical stress. These findings offer a plausible but unproven explanation of reports citing the occurrence of an increased rate of aneurysmal rupture after unrelated surgical procedures H or CABG performed in anticipation of AAA repair.12 In the latter report,12 the influence of the timing of CABG on long-term survival in patients scheduled to have AAA repair was retrospectively assessed. In 23 patients with asymptomatic AAA greater than 5 cm in diameter, those who underwent AAA repair simultaneously or within 2 weeks of CABG suffered no mortality. In nine patients scheduled to undergo AAA repair more than 2 weeks after CABG, three died of rupture of their AAA before the scheduled repair operation. In another series of 70 patients who underwent CABG before AAA resection as part of a two-stage procedure, two patients (2.9%) died as a consequence of a ruptured AAA while in the hospital recovering from their CABG surgery. 13 These data would tend to support the concept of a combined CABG and AAA repair surgery, at least in patients with severe CAD and symptomatic AAA. 14 It is also apparent that considerable cost savings can be realized by performing combined surgery. 15The
From the Department of Anaesthesia, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada. Address reprint requests to Barry A. Finegan, MB, FRCPC, Department of Anaesthesia, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada T6G 2H7. Copyright © 1998 by W.B. Saunders Company 1053-0770/98/1202-002258.00/0 Key words: coronary artery bypass, carotid endartectomy/risk factors, abdominal aortic aneurysm/risk factors
Journal of Cardiothoracic and Vascular Anesthesia, Vo112,No 2 (April), 1998:pp 225-227
225
226
FINEGAN AND KASHKARI
Table 1, Published Results of Combined CABG and A A A Procedures Study
No. Patients
Mortality (%)
Whittemore et a128(1980) David TM (1984) Ruby et al TM (1985) Reul et a127(1986) Emery et al2s (1988) Westaby et a129(1992) Vicaretti et al3° (1994) Black and Desai31 (1995) Mohr et al is (1995)
2 4 6 11 2 8 15 3 25
0 0 0 0 0 25 6.7 0 12
equate to identify patients at risk of adverse cardiovascular outcomes following surgery. 19 CABG AND CAROTID STENOSIS
published results of combined CABG and AAA surgical procedures are shown in Table I. The most recent data constitute the largest series in high-risk patients. 16 Of 25 patients who underwent combined CABG and AAA repair, all had severe CAD with either unstable angina and/or left ventricular ejection fraction (LVEF) <35%. Ten patients had an LVEF <20%. In addition to CABG and AAA, three patients had an aortic valve replacement, two had carotid endarterectomies, and three had renal artery revascularization. The surgical procedure involved CABG followed by AAA surgery. Patients were not weaned from bypass until the distal aortic anastomosis was completed. Three patients died (overall 30-day mortality, 12%), one from an intraoperative myocardial infarction, one from heparin-induced thrombocytopenia, and one from multiorgan failure. Ten patients suffered postoperative complications, the most serious of which were a completed stroke in a patient who had an aortic valve replacement and severe lower limb ischemia requiring amputation in a patient with severe peripheral vascular disease. Actuarial 1-year survival rate was 88%. These data suggest that patients previously considered inoperable may be candidates for combined CABG and AAA repair surgery. COMBINED CABG AND VASCULAR SURGERY FOR AORTIC OCCLUSIVE DISEASE
The very limited data available suggest that there is little benefit to this combination of procedures except in extreme circumstances. Extracorporeal circulation may further impair limb perfusion, and vein harvesting and wound repair in an ischemic limb may be very difficult. 16 CAROTID SURGERY AND CAD
Angiographically normal coronary anatomy was detected in only 9% of 295 patients presenting for carotid endarterectomy, whereas 26% were found to have severe correctable disease. 3 Short-term and long-term mortality in carotid endarterectomy patients is increased in patients with preexisting or occult CAD. 17,t8Patients undergoing carotid surgery should be screened for CAD and simple noninvasive investigations may be ad-
In a retrospective study of 1,779 patients who underwent preoperative carotid duplex scanning before CABG and valve surgery, carotid stenosis of >50% luminal diameter was detected in 263 patients. 2° This finding was the most powerful predictor of postoperative stroke (odds ratio, 6.01). Eighty-one patients has occlusions between 75% and 99% of luminal diameter. D'Agostino et a121 prospectively assessed the incidence and risk factors for stroke in 1,835 patients undergoing first-time CABG: although carotid stenosis >50% was a risk factor in this population, age, perioperative cardiac functional status, and procedure-related factors were also important. Thus, in patients scheduled for elective CABG, a not insignificant number may require carotid endarterectomy. TIMING OF CABG AND CAROTID ARTERY SURGERY
Should CABG and carotid endarterectomy be performed as combined or staged procedures? This issue has been addressed in only one randomized controlled trial,22 in which 129 patients with unstable cardiac disease were prospectively randomized to receive either combined operations or CABG alone, with carotid endarterectomy delayed until the patient had recovered from the cardiac procedure. The composite stroke rate for patients undergoing combined procedures was 2.8%, whereas that for patients in whom delayed carotid endartrectomy was performed within 2 weeks was 14%. Postponing the carotid procedure for a longer interval reduced the risk of staged procedures to that equivalent to the combined group (2.2%). Observational data23 lend further support to the performance of combined procedm-es in which significant surgically correctable cardiovascular and cerebrovascular disease coexist. Recent cost analysis data also support the safety and economic benefit of combined relative to separate staged CABG and carotid endarterectomy procedures. 24 Surgical skill is an essential element in patient outcome after carotid surgery. Participants in the pivotal Asymptomatic Carotid Atherosclerosis Study were subject to prestudy audit of their last 50 cases and were refused participation if their neurologic morbidity and mortality in asymptomatic patients was greater than 3%. 25 This important factor should be considered both in the interpretation of the literature and in advising patients of the risks of combined procedures. CONCLUSION CAD is a common finding in patients scheduled for vascular surgical procedures. Carotid disease is not uncommonly detected in patients scheduled for CABG. Given the availability of skilled anesthesia and surgical personnel, combined AAA and CABG surgery and combined carotid and CABG surgery are safe and cost effective.
REFERENCES
1. Ashton CM: Perioperative myocardial infarction with noncardiac surgery.AmJMed Sci 308:41-48, 1994 2. Dawood MM, Gutpa DK, Southern J, et al: Pathology of fatal perioperative myocardial infarction: Implications regarding pathophysiology and prevention. IntJ Cardio157:37-44, 1996
3. Hertzer NR, Beven EG, Young JR, et al: Coronary artery disease in peripheral vascular patients. A classification of 1000 coronary angiograms and results of surgical management. Ann Surg 199:223233, 1984 4. Ashton CM, Petersen NJ, Wray NP, et al: The incidence of
PRO AND CON
perioperative myocardial infarction in men undergoing noncardiac surgery. Ann Int Med 118:504-510, 1993 5. Szilagyi DE, Smith RF, DeRusso FJ, et al: Contribution of abdominal aortic aneurysmectomy to prolongation of life. Ann Surg 164:678-699, 1966 6. Chen JC, Hildebrand HD, Salvian AJ, et al: Predictors of death in nouruptured and ruptured abdominal aortic aneurysms. J Vasc Surg 24:614-23, 1996 7. Hertzer NR, Young JR, Beven EG, et al: Late results of coronary bypass in patients with infrarenal aortic aneurysms. The Cleveland Clinic Study. Ann Surg 205:360-367, 1987 8. O'Hara PJ, Hertzer NR, Krajewski LP, et al: Ten-year experience with abdominal aortic aneurysm repair in octogenarians: Early results and late outcome. J Vasc Surg 21:830-838, 1995 9. Thompson RW: Basic science of abdominal aortic aneurysms: Emerging therapeutic strategies for an unresolved clinical problem. Curr Opin Cardiol 11:504-518, 1996 10. Shireman PK, McCarthy WJ, Pearce WH, et al: Elevations of tissue-type plasminogen activator and differential expression of urokinase-type plasminogen activator in diseased aorta. J Vasc Surg 25:157164, 1997 11. Swanson RJ, Littooy FN, Hunt TK, Stoney RJ: Laparotomy as a precipitating factor in the rupture of intra-abdominal aneurysms. Arch Surg 115:299-304, 1980 12. Blackbourue LH, Tribble CG, Langenburg SE, et al: Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization. Ann Snrg 219:693-698, 1994 13. Hertzer NR, Young JR, Beven EG, et al: Late results of coronary bypass in patients with peripheral vascular disease. II. Five-year survival according to sex, hypertension, and diabetes. Cleve Clin J Med 54:15-23, 1987 14. Ruby ST, Whittemore AD, Couch NP, et al: Coronary artery disease in patients requiring abdominal aortic anem'ysm repair. Selective use of a combined operation. Ann Surg 201:758-764, 1985 15. David TE: Combined cardiac and abdominal aortic surgery. Circulation 72:II18-21, 1985 16. Molar FW, Falk V, Autschbach R, et al: One-stage surgery of coronary arteries and abdominal aorta in patients with impaired left ventricular function. Circulation 91:379-385, 1995 17. Hertzer NR, Lees CD: Fatal myocardial infarction following carotid endarterectomy: Three hundred thirty-five patients followed 6-11 years after operation. Ann Surg 194:212-218, 1981
227
18. Hertzer NR, Arison R: Cumulative stroke and survival ten years after carotid endarterectomy. J Vasc Surg 2:661-668, 1985 19. Urbinati S, Di Pasquale G, Andreoli A, et al: Preoperative noninvasive coronary risk stratification in candidates for carotid endarterectomy. Stroke 25:2022-2027, 1994 20. Ricotta JJ, Faggioli GL, Castilone A, Hassett JM: Risk factors for stroke after cardiac surgery: Buffalo Cardiac-Cerebral Study Group. J Vasc Surg 21:359-64, 1995 21. D'Agostino RS, Svensson LG, Neumann DJ, et al: Screening carotid ultrasonography and risk factors for stroke in coronary artery surgery patients. Ann Thorac Surg 62:1714-1723, 1996 22. Hertzer NR, Loop FD, Beven EG, et al: Surgical staging for simultaneous coronary and carotid disease: A study including prospective randomization. J Vasc Surg 9:455-463, 1989 23. Akins CW, Moncure AC, Daggett WM, et al: Safety and efficacy of concomitant carotid and coronary artery operations. Ann Thorac Surg 60:311-318, 1995 24. Daily PO, Freeman RK, Dembitsky WP, et al: Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting. J Thorac Cardiovasc Surg 111:1185-1193, 1996 25. Moore WS, Young B, Baker WH, et al: Surgical results: A justification of the surgeon selection process for the ACAS trial. The ACAS Investigators. J Vasc Surg 23:323-328, 1996 26. Whittemore AD, Clowes AW, Hechtman HB, Mannick JA: Aortic anenrysm repair. Reduced operative mortality associated with maintenance of optimal cardiac performance. Ann Surg 192:414-421, 1980 27. Reul GJ Jr, Cooley DA, Duncan JM, et al: The effect of coronary bypass on the outcome of peripheral vascular operations in 1093 patients. J Vasc Surg 3:788-798, 1986 28. Emery RW, Ott RA, Bernhard V, et al: Surgical approach to combined coronary revascularization and abdominal aortic aneurysmectomy. J Cardiovasc Surg (Torino) 29:143-145, 1988 29. Westaby S, Parry A, Grebenik CR, et al: Combined cardiac and abdominal aortic aneurysm operations. The dual operation on cardiopulmonary bypass. J Thorac Cardiovasc Surg 104:990-995, 1992 30. Vicaretti M, Fletcher JP, Richardson A, et al: Combined coronary artery bypass grafting and abdominal aortic aneurysm repair. Cardiovasc Surg 2:340-343, 1994 31. Black JJ, Desai JB: Combined coronary artery bypass surgery and abdominal aortic aneurysm repair. J R Soc Med 88:350P-352P, 1995