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4 Vascular Surgery
40 Atropine 2 mg
30
20
Stopping reasons:
Target heart rate
10
5
Side effects
Ischemia
Echocardiography
Heart rate/Blood pressure
Fig. 1.1.
The normal stress protocol, with increasing doses of dobutamine and test endpoints.
6
1
15
16
LAX
17
11
10
13
8
6
10
9
7
8
SAX
17
14
12
1 = normal
2 = mild hypokinesia
7
9
3 = severe hypokinesia
4 = akinesia
5
3
4
2
5 = dyskinesia
minutes0 5 10 1913 16
LAD
RCA
LCX
4CH
Fig. 1.2.
The scoring of the left ventricle for wall motion abnormalities. LAX, long axis; SAX, short axis; 4CH, four
2CH
chambers; 2CH, two chambers; LAD, left anterior descending artery; RCA, right coronary artery; LCX, left circumflex artery.
Preoperative Cardiac Risk Assessment and Management of Elderly Men 5
Fig. 1.3.
An example of a normal resting echocardiogram, showing respectively, apical views and one short-axis
view.
multiple risk factors and the planned high-risk surgery a dobutamine stress echocardiography was performed. Fig. 1.1 shows the normal stress protocol, with increasing
doses of dobutamine and test endpoints. In Fig. 1.2 the scoring of the left ventricle
for wall motion abnormalities is shown. Fig. 1.3 is an example of a normal resting
echocardiogram, showing respectively, apical views and one short-axis view. In Fig.
1.4, the different stages of the stress test are shown for the apical four-chamber view:
rest, low-dose dobutamine, peak dose dobutamine, and recovery. As indicated by
arrows, the posterior septum shows an outward movement during peak stress, suggesting dyskinesia, and myocardial ischemia of the posterior septum.
Question 2
Postoperative outcome in patients undergoing major vascular surgery has been
improved in those taking beta-blockers and statins. Medical therapy may reduce the
need for additional preoperative testing for coronary artery disease as the incidence
of perioperative cardiac mortality is reduced to less than 1 percent, and may even
reduce the indications for preoperative coronary revascularization.
A. Beta-blockers are associated with a reduced perioperative cardiac event rate in
patients undergoing vascular surgery, both in retrospective and prospective
studies.
6 Vascular Surgery
Fig. 1.4.
The different stages of the stress test of the apical four-chamber view, rest, low-dose dobutamine, peak
dose dobutamine, and recovery. As shown and indicated with arrows, the posterior septum shows an outward
movement during peak stress, suggestive of dyskinesia, and also myocardial ischemia of the posterior septum.
B. Statin use is associated with an improved postoperative outcome.
C. Statin use is not associated with an increased incidence of perioperative myopa-
thy.
D. Beta-blockers and statins are independently associated with an improved post-
operative outcome.
Question 3
Preoperative beta-blocker therapy is widely used. However, the dose and duration
of preoperative therapy is uncertain.
A. Beta-blockers should be started preferably 30 days prior to surgery.
B. Beta-blockers should be initiated several hours before surgery.
C. Heart rate control should be aimed at a heart rate between 90 and 100 bpm.
D. Heart rate control should be aimed at a heart rate between 60 and 70 bpm.
In this patient beta-blockers were started 6 weeks before surgery. Starting dose of
bisoprolol was 2.5 mg; the dose was increased to 5.0 mg to obtain a resting heart
between 60 and 70 bpm.
Preoperative Cardiac Risk Assessment and Management of Elderly Men 7
Question 4
Perioperative statin therapy has recently been introduced to improve postoperative
outcome.
A. Statins improve postoperative outcome by reducing the cholesterol level.
B. Withdrawal of perioperative statin therapy is associated with an increased peri-
operative cardiac event rate.
C. Perioperative statin use is associated with an increased incidence of myopathy.
D. Perioperative statin use is associated with a reduced perioperative cardiac event
rate in vascular surgery patients only.
Statins were prescribed in this patient, Lescol XL 80 mg daily, at the same time as
beta-blockers were introduced.
Question 5
Preoperative coronary revascularization seems to be an attractive option to improve
not only direct postoperative outcome in high-risk patients but also long-term survival after surgery.
A. Preoperative coronary revascularization improves postoperative outcome in all
patients with significant coronary artery disease prior to major vascular surgery.
B. Preoperative coronary revascularization in patients with one- or two-vessel
disease is not associated with an improved postoperative outcome compared to
patients receiving medical therapy.
C. Preoperative coronary revascularization is associated with an improved 2-year
outcome compared to medical therapy.
D. Patients with proven coronary artery disease who are treated medically are at
increased risk of late coronary revascularization after surgery. After late revascularization, long-term outcome is similar to that with revascularization prior to
surgery.
This 72-year-old male had multiple cardiac risk factors: elderly age, angina pectoris,
diabetes mellitus, and a previous MI. He underwent a noninvasive stress test, dobutamine stress echocardiography, which showed myocardial ischemia, suggesting left
anterior descending artery (LAD) disease. Beta-blockers and statins were prescribed
and continued during surgery. Surgery was uneventful; after 2 years angina pectoris
complaints increased and a PTCA procedure was successfully performed on the LAD.
Commentary
Cardiac complications are the major cause of perioperative morbidity and mortality, which may occur in 1–5 percent of unselected patients undergoing major
8 Vascular Surgery
vascular surgery [1]. [Q1: A] This high frequency of cardiac complications is related
to the high prevalence of coronary artery disease; 54 percent of patients undergoing
major vascular surgery have advanced or severe coronary artery disease and only 8
percent of patients have normal coronary arteries [2]. Perioperative cardiac complications are equally caused by prolonged myocardial ischemia or by coronary artery
plaque rupture with subsequent thrombus formation and coronary artery occlusion
[1, 3]. [Q1: B, C, D] Prolonged perioperative myocardial ischemia usually occurs from
either increased myocardial oxygen demand or reduced supply, or from a combination of the two. There are several perioperative factors that can increase myocardial
oxygen demand including tachycardia and hypertension resulting from surgical
stress, postoperative pain, interruption of beta-blocker use, or the use sympathomimetic drugs. Decreased oxygen supply, on the other hand, can occur as a result
of hypotension, vasospasm, and anemia, hypoxia or coronary artery plaque rupture.
Beta-blockers primarily reduce myocardial oxygen demand, while statins may
prevent coronary artery plaque rupture. [Q2: A, B]
Beta-Adrenergic Antagonists
Several retrospective and prospective clinical trials have shown that perioperative
use of beta-blockers is associated with reduction in the incidence of postoperative
myocardial ischemia, nonfatal myocardial infarction and cardiac death [4–6].
[Q2: A] The majority of these studies were small in sample size, and the studies were
designed to explore the protective effect of beta-blockers for the reduction of perioperative myocardial ischemia. To overcome the limitations of these studies two
randomized clinical trials addressed the issue of perioperative use of beta-blockers
for the prevention of cardiac death and myocardial infarction. Mangano et al. [7]
studied the effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery including vascular surgery. The investigators enrolled and randomized 200 patients to atenolol (given intravenously before and immediately
after surgery and orally thereafter for the duration of hospitalization) or placebo.
No difference was observed in 30-day mortality but mortality was significantly
lower at 6 months following discharge (0% vs. 8 %, p < 0.001), over the first year
(3% vs. 14%, p = 0.005), and over 2 years (10% vs. 21%, p = 0.019). The apparent
lack of a perioperative cardioprotective effect of atenolol in this study was probably related to the small sample size, and the fact that patients at low risk for cardiac
complications were studied. In a more recent study, Poldermans et al. [8] clearly
demonstrated the cardioprotective effect of perioperative beta-blocker use for the
reduction of perioperative cardiac death and myocardial infarction in high-risk
patients undergoing major vascular surgery. In total, 112 high-risk vascular
patients were selected using a combination of cardiac risk factors and positive
results on dobutamine stress echocardiography. Patients were then randomly
assigned to standard care or standard care with bisoprolol use. Bisoprolol was
started at least 30 days prior to surgery; the dose was adjusted to aim at a resting
heart rate of 60–70 bpm. [Q3: A, B, C, D] The results showed that the incidence of the
combined endpoint of cardiac death and myocardial infarction within 30 days of
surgery was significantly lower in patients using bisoprolol compared to patients in
the control group (combined endpoint 3.3% in the bisoprolol group vs. 34% in the
control group). Based on the findings of these studies, beta-blocker use has been
recommended by the ACC/AHA Guidelines on Perioperative Cardiovascular
Preoperative Cardiac Risk Assessment and Management of Elderly Men 9
Evaluation for Noncardiac Surgery in high-risk patients with a positive stress test
as a level one recommendation [4].
3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitors (Statins)
Although perioperative use of beta-blockers has been associated with a significant
reduction in cardiac mortality and morbidity, still some patients with multiple
cardiac risk factors and positive stress test results may remain at considerable risk
for perioperative cardiac mortality [9]. For these patients additional cardioprotective medication such as statin use may offer an important addition to preoperative
risk reduction strategies. The association between statin use and possible reduction
in perioperative cardiac complications may result from the favorable actions of
statins on atherosclerosis and from their vascular properties other than those attributed to cholesterol lowering [10–12]. [Q4: A, B, C] These so-called pleiotropic effects
of statins may attenuate coronary artery plaque inflammation and influence plaque
stability in addition to antithrombogenic, antiproliferative and leukocyte-adhesion
inhibiting effects [13–15]. All these effects of statins may stabilize unstable coronary
artery plaques, thereby reducing myocardial ischemia and subsequent myocardial
damage.
There are only a few studies that have evaluated the beneficial effects of perioperative statin use in reducing perioperative cardiac complications [16–18].
Poldermans et al. [16], using a case-control study design in 2816 patients who
underwent major vascular surgery, showed that controls more often were statin
users than cases, which resulted in a fourfold reduction in all-cause mortality
within 30 days after surgery. This finding was consistent in subgroups of patients
according to type of vascular surgery, cardiac risk factors and beta-blocker use.
[Q2: D] Similar to these findings, Durazzo et al. [17] also reported a significantly
reduced incidence of cardiovascular events within 6 months of vascular surgery in
patients who were randomly assigned to atorvastatin compared with placebo
(atorvastatin vs. placebo, 8.3% vs. 26.0%). Finally, the study results of Lindenauer
et al. [18] indicated that statin use was associated with 28 percent relative risk
reduction of in-hospital mortality compared to no statin use in 780,591 patients
undergoing major noncardiac surgery. [Q4: D] The results of these studies are
important indications of the possible beneficial effect of perioperative statin use.
However, certain limitations such as the retrospective nature of the study of
Poldermans et al. and Lindenauer et al., the relatively small sample size (n = 100
patients) of the study of Durazzo et al., and the lack of information about the
optimal timing and duration of statin therapy warrant future clinical trials to
confirm the effectiveness and safety of statin therapy in patients undergoing major
noncardiac surgery. Initially, statin use was contraindicated in the perioperative
period as it was thought that drug interactions might increase the incidence of
myopathy and in combination with analgesics this might even remain asymptomatic. However, a recent study showed no increased incidence of myopathy
among statin users [19]. Statin users undergoing vascular surgery at the Erasmus
MC were screened for myopathy by measuring creatine kinase (CK) levels at
regular intervals and checking for clinical symptoms. In 981 patients no relation
was found between statin use and CK levels. Also, no patient experienced myopathy symptoms. Importantly, no deleterious effect of temporary statin interruption
was observed. [Q2: C and Q4: B, C]
10 Vascular Surgery
Preoperative cardiac risk evaluation may identify high-risk patients for whom the
risk of perioperative cardiac complications without further coronary assessment
and subsequent intervention could be too high. For these patients either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) may be considered.
Percutaneous Revascularization
There have been several studies evaluating the clinical utility of PTCA in high-risk
patients undergoing major noncardiac surgery including vascular surgery. In the
studies of Elmore et al. [20] and Gottlieb et al. [21], retrospective data were collected
of patients who underwent PTCA prior to surgery. These patients were referred for
PTCA because of the need to relieve symptomatic angina or to treat myocardial
ischemia identified by noninvasive testing. The findings of these studies indicated
that the incidence of perioperative cardiac death and myocardial infarction was low,
but the investigators in these studies failed to use a comparison group of patients
with coronary artery disease not treated with PTCA. The apparent limitations of
these studies prompted Posner et al. [22] to conduct their own investigation to
compare adverse cardiac outcomes after noncardiac surgery in patients with prior
PTCA, patients with non-revascularized coronary artery disease and normal controls. The results showed that patients treated with PTCA within 90 days of noncardiac surgery had a similar incidence of perioperative events to matched patients
with coronary artery disease who had not been revascularized. [Q5: A] Those patients
who underwent a PTCA procedure 90 days earlier then the day of noncardiac
surgery had a lower risk of cardiac events than non-revascularized patients but not
as low as normal controls. Furthermore, the effect of revascularization was limited
to a reduction in the incidence of angina pectoris and congestive heart failure and
there was no reduction in the incidence of death and nonfatal myocardial infarction. Indeed, the recent findings of the Coronary Artery Revascularization
Prophylaxis (CARP) trial [23] also showed that coronary revascularization with
PTCA or CABG prior to vascular surgery in high-risk cardiac stable patients did not
provide short-term survival benefit or better long-term event-free survival rate.
[Q5: B, C, D] The findings of the study indicated that patients undergoing coronary
revascularization prior to vascular surgery had a 3.1 percent mortality rate within
30 days of vascular surgery compared to a 3.4 percent rate for those not having
coronary revascularization (p = 0.87). Additionally, the rate of perioperative nonfatal myocardial infarction as detected by troponin elevation was also similar in
coronary revascularization patients and patients not undergoing coronary revascularization (11.6% vs. 14.3%, p = 0.37). Furthermore, the results of the trial also indicated that coronary revascularization prior to vascular surgery was associated with
delay or cancellation of the required vascular operation. Apart from these findings,
it is also important to note that if a PTCA procedure and coronary stent placement
are performed less than 6 weeks before major noncardiac surgery, the risk of perioperative coronary thrombosis or major bleeding complications may be substantially increased [24, 25]. Two separate small-scale studies reported an increased rate
of serious bleeding complications if antithrombotic therapy was continued until the
time of surgery, and in patients in whom antiplatelet drugs were interrupted one or
two days before surgery an increased rate of fatal events was observed due to stent
thrombosis [24, 25]. The risk of these complications persisted for 6 weeks after
Preoperative Cardiac Risk Assessment and Management of Elderly Men 11
coronary stent placement. Patients who underwent surgery more than 6 weeks after
coronary stent placement experienced no adverse cardiac events. These observations indicate that if PTCA with stenting is planned in the weeks or months before
noncardiac surgery then a delay of at least 6 weeks should occur before noncardiac
surgery to allow for completion of the dual antiplatelet therapy and re-endothelialization of the stent.
Coronary Artery Bypass Grafting
The results of the largest retrospective study to date indicated that CABG had a protective effect prior to noncardiac surgery [26]. Data for 3368 patients analyzed from
the Coronary Artery Surgery Study (CASS) registry showed that patients who
underwent CABG before abdominal, vascular, thoracic, or head and neck surgery
had a lower incidence of perioperative mortality (3.3% vs. 1.7%) and myocardial
infarction (2.7% vs. 0.8%) compared with medically treated patients. The largest
reduction in perioperative mortality was observed in patients with a history of
advanced angina and in patients with multivessel coronary artery disease. In a more
recent study, data analyzed from a random sample of Medicare beneficiaries
showed that preoperative coronary revascularization was associated with a reduction in 1-year mortality for patients undergoing aortic surgery but showed no effect
on mortality in those undergoing infrainguinal procedures [27]. Hassan et al. [28],
using data from the Bypass Angioplasty Revascularization Investigation, showed
there was no difference in the incidence of cardiac death and myocardial infarction
between patients who underwent coronary angioplasty or CABG and subsequent
noncardiac surgery (coronary angioplasty group, 1.6% vs. CABG group, 1.6%).
[Q5: A] As mentioned above under ‘Percutaneous revascularization’, the recent
findings of the CARP trial showed that high-risk patients randomized to coronary
revascularization prior to vascular surgery had no better perioperative and longterm cardiac complication rates than medically treated patients. Therefore, in the
light of these findings a decision to proceed with coronary angioplasty and selective
revascularization before high-risk surgery should be made independent of the need
for major noncardiac surgery [4].
References
1. Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990;72(1):153–84.
2. 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
1984;199(2):223–33.
3. Dawood MM, Gutpa DK, Southern J, Walia A, Atkinson JB, Eagle KA. Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention. Int J Cardiol
199615;57(1):37–44.
4. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular
evaluation for noncardiac surgery – executive summary: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update
the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
Circulation 200212;105(10):1257–67.
5. Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ. Cardiac risk of noncardiac surgery:
influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and
University of Michigan Heart Care Program. Coronary Artery Surgery Study. Circulation
199716;96(6):1882–7.
12 Vascular Surgery
6. Boersma E, Poldermans D, Bax JJ, et al. Predictors of cardiac events after major vascular surgery:
role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA
2001;285(14):1865–73.
7) Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl
J Med 1996;335(23):1713–20.
8. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and
myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic
Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med
1999;341(24):1789–94.
9. Devereaux PJ, Leslie K, Yang H. The effect of perioperative beta-blockers on patients undergoing
noncardiac surgery – is the answer in? Can J Anaesth 2004;51(8):749–55.
10. Takemoto M, Liao JK. Pleiotropic effects of 3-hydroxy-3-methylglutaryl coenzyme A reductase
inhibitors. Arterioscler Thromb Vasc Biol 2001;21(11):1712–9.
11. Huhle G, Abletshauser C, Mayer N, Weidinger G, Harenberg J, Heene DL. Reduction of platelet activity markers in type II hypercholesterolemic patients by a HMG-CoA-reductase inhibitor. Thromb
Res 1999;95(5):229–34.
12. Hernandez-Perera O, Perez-Sala D, Navarro-Antolin J, et al. Effects of the 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, atorvastatin and simvastatin, on the expression of endothelin-1 and
endothelial nitric oxide synthase in vascular endothelial cells. J Clin Invest 1998;101(12):2711–2719.
13. Stamler JS, Loh E, Roddy MA, Currie KE, Creager MA. Nitric oxide regulates basal systemic and pulmonary vascular resistance in healthy humans. Circulation 1994;89(5):2035–40.
14. Kurowska EM. Nitric oxide therapies in vascular diseases. Curr Pharm Des 2002;8(3):155–66.
15. van Haelst PL, van Doormaal JJ, May JF, Gans RO, Crijns HJ, Cohen Tervaert JW. Secondary prevention with fluvastatin decreases levels of adhesion molecules, neopterin and C-reactive protein. Eur J
Intern Med 2001;12(6):503–9.
16. Poldermans D, Bax JJ, Kertai MD, et al. Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery. Circulation
2003;107(14):1848–51.
17. Durazzo AES, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular events after vascular
surgery with atorvastatin: a randomized trial. J Vasc Surg 2004;39(5):967–75.
18. Lindenauer PK, Pekow P, Wang K, Gutierrez B, Benjamin EM. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA 2004;291(17):2092–9.
19. Schouete O, Kertai MD, Bax JJ, et al. Safety of statin use in high-risk patients undergoing major vascular surgery. Am J Cardiol 2005;95(5):658–660.
20. Elmore JR, Hallett JW, Jr, Gibbons RJ, et al. Myocardial revascularization before abdominal aortic
aneurysmorrhaphy: effect of coronary angioplasty. Mayo Clin Proc 1993;68(7):637–41.
21. Gottlieb A, Banoub M, Sprung J, Levy PJ, Beven M, Mascha EJ. Perioperative cardiovascular morbidity in patients with coronary artery disease undergoing vascular surgery after percutaneous transluminal coronary angioplasty. J Cardiothorac Vasc Anesth 1998;12(5):501–6.
22. Posner KL, Van Norman GA, Chan V. Adverse cardiac outcomes after noncardiac surgery in patients
with prior percutaneous transluminal coronary angioplasty. Anesth Analg 1999;89(3):553–60.
23. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004;351:2795–804.
24. Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. Catastrophic outcomes of noncardiac surgery
soon after coronary stenting. J Am Coll Cardiol 2000;35(5):1288–94.
25. Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing non-cardiac surgery
in the two months following coronary stenting. Journal of the American College of Cardiology
2003;42(2):234–40.
26. Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ. Cardiac risk of noncardiac surgery:
influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and
University of Michigan Heart Care Program. Coronary Artery Surgery Study. Circulation
1997;96(6):1882–7.
27. Fleisher LA, Eagle KA, Shaffer T, Anderson GF. Perioperative- and long-term mortality rates after
major vascular surgery: the relationship to preoperative testing in the Medicare population. Anesth
Analg 1999;89(4):849–55.
28. Hassan SA, Hlatky MA, Boothroyd DB, et al. Outcomes of noncardiac surgery after coronary bypass
surgery or coronary angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI).
Am J Med 2001;110(4):260–6.
2. Abdominal Aortic Aneurysm
Jean-Pierre Becquemin and Alexandre d’Audiffret
A 59-year-old man presented with an abdominal aortic aneurysm (AAA) discovered on duplex scan examination of the abdomen. The AAA was 60-mm large
and extended to the left common iliac artery. The patient was otherwise asymptomatic, with no abdominal or back pain. His medical history was significant for
hypertension controlled by bitherapy, non-insulin-dependent diabetes diagnosed
5 years previously, claudication with a walking distance of 400 metres, and a
smoking history of 40 packs/year. He had no history of myocardial infarction
(MI) or angina pectoris.
He had a positive family history for an aneurysm. His father underwent
surgery 20 years earlier for an abdominal aneurysm. He also has a brother who is
70 years old and a sister who is 55 years old with apparently no health problems
On examination, the patient was obese. No abdominal mass was palpated.
A computed tomography (CT) scan was performed (Figs 2.1 and 2.2).
Routine blood tests were normal except for serum creatinine level, which was
200 mg/ml. Electrocardiogram (ECG) was normal.
Question 1
The AAA of this patient was found during a routine screening. In which group(s) of
population is duplex scan screening for AAA justified?
A. Patients with uncomplicated hypertension.
B. Patients with a family history of aneurysmal disease.
C. Patients with a smoking history.
D. Patients with peripheral vascular disease.
E. Obese patients with vascular risk factors
F. All men, starting at the age of 50 years.
13
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