- Email: [email protected]
Simultaneous revascularization for critical coronary and peripheral vascular ischemia
JOURNAL OF VASCULAR Volume 18, Number 2
SURGERY
in the control group and the group with PVD, differences were seen only in total cholesterol and cholesterol and triglyceride content of the IDL fraction. Comparison between those with moderate and severe disease demonstrated an increasein IDL cholesterol and triglyceride and a decreasein HDL cholesterol with more severe disease. There was no difference in the proportion of apolipoprotein E phenotypes. The authors conclude that IDL abnormalities play an important role in development and severity of peripheral vascular disease. Although this is an interesting study, the data do not support the conclusion. Although, the statistical analysis used is adequate for comparing independent variables, its appropriateness for the complex analysis of interrelated variables such as lipid indexes is questionable. Furthermore, although this type of study can demonstrate an association, no causal relationship can or should be assumed. This type of study can only suggest that serum lipid levels are a factor in the development of PVD. It does not provide sufficient evidence to implement therapy directed toward changing IDL content. These decisions must await future studies that correlate progression, rather than presence, of diseasewith serial determinations of lipid indexes. B. Timothy Baxter, AJLI Universiy of Nebraska
Simultaneous and peripheral
revascularization vascular ischemia
for
critical
coronary
Carrel T, Niederhauser U, PasicM, Gallino A, von Segesser L, Turina M. Ann Thorac Surg 1991;52:805-9. This report summarizes an experience with 32 patients who underwent simultaneous coronary artery bypass grafting and a peripheral vascular operation for occlusive diseaseunder the same anesthetic. The authors state that such combined operation was occasioned by critical and severely symptomatic disease in both vascular territories. With the exception of three femoral popliteal bypassgrafts, the vascular surgery procedures involved operation on the aortoiliac segments. Certainly the practice of vascular surgery at the University Hospital in Zurich, Switzerland, differs significantly from that performed in this country; 19 of the 32 vascular procedures were aortoiliac or iliofemoral endarterectomies, whereas there were but 10 aortoiliac or aortofemoral bypass grafts for occlusive disease. Furthermore, sevenof the 32 operations performed for peripheral occlusive diseasewere in patients with claudication alone. It is clear that the authors have a commitment to the concept of combined operations. Although this report considers 32 combined operations carried out where the vascular problem was peripheral occlusive disease, the authors mention that this is from a pool of 135 simultaneous coronary and vascularoperations performed over the interval 1978 to 1990. Presumably the balance of these procedures represents simultaneous coronary and carotid artery or abdominal aortic aneurysm operations. Indeed, there is an interesting graph in the text of the article indicating that in 1990, 8% of all coronary artery bypasses
performed at their institution were combined with a simultaneous vascular surgery procedure. The technical aspectsof their operations are interesting in that a single surgical team performed both the coronary and vascular operations. The statement is made in their article that an expeditious operation is part of the overall treatment strategy. Indeed, operative time for such involved procedures was a very admirable mean of 3.75 hours! Early mortality rate was 3.1% and not significantly different from the mortality rate associated with isolated coronary bypass in patients with comparable patterns of coronary disease.Repeat operation for early vascular graft failure was required in a single patient. Long-term survival rate was nearly 90% in this small group of patients, and the authors make the point that this is similar to the survival rate after isolated coronary artery bypass grafting in patients operated on at their hospital but considerably superior to the late survival in patients undergoing isolated repair of abdominal aortic aneurysm or peripheral vascular operation for occlusivedisease.Thus an aggressiveposture toward coronary artery disease is advocated to increase long-term survival in patients requiring peripheral vascular operation. The authors have demonstrated in a small number of patients that acceptable morbidity and long-term survival rates can be achieved by simultaneous performance of coronary and peripheral vascular operations. They conclude that this type of combined approach is likely to be used with increasing frequency in the future. I disagree with this conclusion. Although we embrace the concept of combined operation for patients with simultaneous carotid artery and coronary artery disease,coronary bypasshas not been combined with aortoiliac reconstructive surgery in our unit. Despite the fact that the authors have demonstrated the safety of a combined approach in their hands, this begs the issue of whether such a combined operation is necessary or desirable. In most patients with truly pressing indications for treatment in both vascular territories, our preference is initial coronary revascularization, which can be followed within days, if necessary, by aortoiliac reconstruction. Alternatively, in those circumstances where peripheral revascularization is the clear priority, a variety of low-risk treatment options, familiar to all vascular surgeons, can be applied. Richard P. Cambriu, ML2 Massacbssem General Hospital Boston, Mass.
Complications and validity of pulmonary in acute pulmonary embolism
angiography
Stein PD, Athanasoulis C, Alvavi A, et al. Circulation 1992;85:462-8. This is a sequel to the initial publication from the Prospective Investigation of Pulmonary Embolism Diagnosis study that reported on the value of ventilationperfusion scans with pooled data collected from nine centers. The purpose of this investigation was to use the
SURGERY
in the control group and the group with PVD, differences were seen only in total cholesterol and cholesterol and triglyceride content of the IDL fraction. Comparison between those with moderate and severe disease demonstrated an increasein IDL cholesterol and triglyceride and a decreasein HDL cholesterol with more severe disease. There was no difference in the proportion of apolipoprotein E phenotypes. The authors conclude that IDL abnormalities play an important role in development and severity of peripheral vascular disease. Although this is an interesting study, the data do not support the conclusion. Although, the statistical analysis used is adequate for comparing independent variables, its appropriateness for the complex analysis of interrelated variables such as lipid indexes is questionable. Furthermore, although this type of study can demonstrate an association, no causal relationship can or should be assumed. This type of study can only suggest that serum lipid levels are a factor in the development of PVD. It does not provide sufficient evidence to implement therapy directed toward changing IDL content. These decisions must await future studies that correlate progression, rather than presence, of diseasewith serial determinations of lipid indexes. B. Timothy Baxter, AJLI Universiy of Nebraska
Simultaneous and peripheral
revascularization vascular ischemia
for
critical
coronary
Carrel T, Niederhauser U, PasicM, Gallino A, von Segesser L, Turina M. Ann Thorac Surg 1991;52:805-9. This report summarizes an experience with 32 patients who underwent simultaneous coronary artery bypass grafting and a peripheral vascular operation for occlusive diseaseunder the same anesthetic. The authors state that such combined operation was occasioned by critical and severely symptomatic disease in both vascular territories. With the exception of three femoral popliteal bypassgrafts, the vascular surgery procedures involved operation on the aortoiliac segments. Certainly the practice of vascular surgery at the University Hospital in Zurich, Switzerland, differs significantly from that performed in this country; 19 of the 32 vascular procedures were aortoiliac or iliofemoral endarterectomies, whereas there were but 10 aortoiliac or aortofemoral bypass grafts for occlusive disease. Furthermore, sevenof the 32 operations performed for peripheral occlusive diseasewere in patients with claudication alone. It is clear that the authors have a commitment to the concept of combined operations. Although this report considers 32 combined operations carried out where the vascular problem was peripheral occlusive disease, the authors mention that this is from a pool of 135 simultaneous coronary and vascularoperations performed over the interval 1978 to 1990. Presumably the balance of these procedures represents simultaneous coronary and carotid artery or abdominal aortic aneurysm operations. Indeed, there is an interesting graph in the text of the article indicating that in 1990, 8% of all coronary artery bypasses
performed at their institution were combined with a simultaneous vascular surgery procedure. The technical aspectsof their operations are interesting in that a single surgical team performed both the coronary and vascular operations. The statement is made in their article that an expeditious operation is part of the overall treatment strategy. Indeed, operative time for such involved procedures was a very admirable mean of 3.75 hours! Early mortality rate was 3.1% and not significantly different from the mortality rate associated with isolated coronary bypass in patients with comparable patterns of coronary disease.Repeat operation for early vascular graft failure was required in a single patient. Long-term survival rate was nearly 90% in this small group of patients, and the authors make the point that this is similar to the survival rate after isolated coronary artery bypass grafting in patients operated on at their hospital but considerably superior to the late survival in patients undergoing isolated repair of abdominal aortic aneurysm or peripheral vascular operation for occlusivedisease.Thus an aggressiveposture toward coronary artery disease is advocated to increase long-term survival in patients requiring peripheral vascular operation. The authors have demonstrated in a small number of patients that acceptable morbidity and long-term survival rates can be achieved by simultaneous performance of coronary and peripheral vascular operations. They conclude that this type of combined approach is likely to be used with increasing frequency in the future. I disagree with this conclusion. Although we embrace the concept of combined operation for patients with simultaneous carotid artery and coronary artery disease,coronary bypasshas not been combined with aortoiliac reconstructive surgery in our unit. Despite the fact that the authors have demonstrated the safety of a combined approach in their hands, this begs the issue of whether such a combined operation is necessary or desirable. In most patients with truly pressing indications for treatment in both vascular territories, our preference is initial coronary revascularization, which can be followed within days, if necessary, by aortoiliac reconstruction. Alternatively, in those circumstances where peripheral revascularization is the clear priority, a variety of low-risk treatment options, familiar to all vascular surgeons, can be applied. Richard P. Cambriu, ML2 Massacbssem General Hospital Boston, Mass.
Complications and validity of pulmonary in acute pulmonary embolism
angiography
Stein PD, Athanasoulis C, Alvavi A, et al. Circulation 1992;85:462-8. This is a sequel to the initial publication from the Prospective Investigation of Pulmonary Embolism Diagnosis study that reported on the value of ventilationperfusion scans with pooled data collected from nine centers. The purpose of this investigation was to use the