Preoperative Coronary Revascularization in High-Risk Patients Undergoing Vascular Surgery

To the Editor: In a recent article Garcia and McFalls1 based their argument against patients undergoing coronary artery revascularization before vascular surgery on the results from two recent prospective studies: the Coronary Artery Revascularization Prophylaxis (CARP) trial2 whose lead author was McFalls, and the DECREASE-V study3 by Poldermans et al. CARP demonstrated a general lack of benefit whereas DECREASE-V showed no benefit even for patients with severe ischemic heart disease. However, the former did not focus on high-risk patients, and neither article focused on patients having open aortic surgery. Femoral-popliteal artery bypass surgery provokes relatively little cardiac stress, whereas in open aortic aneurysm resection the stress may be extreme. Open aortic procedures are associated with potential hemorrhage. Aortic cross clamping provokes a large increase in afterload, and de-clamping may provoke hypotension. Additionally, following open procedures, there are major third space fluid shifts, and potential respiratory compromise. In the CARP study2 patients undergoing open abdominal aortic versus infrainguinal arterial reconstruction formed only 40% of the total. In the DECREASE-V study3 the proportion was 59%. CARP2 dramatically changed thinking when it was published in 2004. However, no prospective study has assessed outcome after preoperative coronary revascularization in patients with severe ischemic heart disease having exclusively open aortic surgery, which I suggest is likely to provide the clearest benefit for preoperative coronary revascularization. In a paper describing a retrospective study of patients with severe surgically correctable coronary artery disease, Hertzer et al. did show a marked survival benefit for coronary artery bypass grafting preceding abdominal aortic aneurysm resection, persisting to 5 yr.4 Peter Tinits, MD, FRCPC Stratford General Hospital Department of Anesthesia 46 General Hospital Drive Stratford, ON N5A2Y6, Canada [email protected]