Coronary and major vascular disease: aggressive screening and priority-based therapy

It is well know that atherosclerosis can simultaneously affect different vascular subsystems, and patients with diffuse atherosclerosis can be a major management problem both for preoperative evaluation and for intraoperative management. The authors have conducted a prospective study to evaluate the prevalence of coronary artery disease in arteriopathic patients, and vice versa, to assess the effectiveness of aggressive screening together with a priority-based approach. Study 1 consisted of 1,000 consecutive non-emergent patients who were affected by abdominal aortic or carotid disease and were screened for the presence of coronary artery disease before surgery with a newly developed clinical risk assessment. They were stratified into three risk categories with different preoperative evaluation strategies. When coronary artery disease was concomitantly demonstrated in these patients, the choice of surgical method was based on priorities, and the use of combined surgical procedures as required. In study 2, 1,000 consecutive patients that required coronary angiography for suspected coronary artery disease were screened for the presence of carotid or abdominal aortic pathology, directly in the cardiac catheter laboratory during coronary angiography, by obtaining views of the aortic arch and abdominal aorta. Surgical approaches paralleled those of study 1. The results for study 1 showed that 720 patients (72%) were affected by abdominal aortic disease, 238 (24%) by carotid disease and 42 (4%) by both pathologies. Significant coronary artery disease was found in 152 patients (15%), of these 123 (81.5%) were affected by abdominal aortic disease and 29 (18.5%) by carotid artery disease. Abdominal aortic surgery was performed directly or after myocardial revascularization, with an overall mortality rate of 4/718 (0.6%), and a perioperative myocardial infarction rate of 10/718 (1.4%). For patients with carotid artery disease, the completed screening and possible therapy for coronary artery disease resulted in an in-hospital mortality rate of 2/238 (0.8%), and a perioperative myocardial infarction rate of 2/238 (0.8%). There were no significant differences in these rates between patients with or without coronary artery disease. Results for study 2 showed that of the 1000 consecutive patients enrolled for suspicion of coronary artery disease, 767 (77%) were affected by significant coronary artery disease. Among these, 38 (4.9%) had a surgically correctable aortic disease and 31 (4%) a surgically correctable carotid disease, which was monolateral and bilateral in 22 (74%) and nine (26%) patients, respectively, and four (0.5%) were diagnosed with both pathologies. These arteriopathic patients were treated for their coronary and vascular disease with no in-hospital mortality nor perioperative myocardial infarction. In patients with multiple vascular involvement, both coronary and vascular surgery can be performed with low risk when aggressive screening and priority-based therapy are adopted.