J Korean Surg Soc.  2013 Mar;84(3):178-184.

Cardiac risk factors of revascularization in chronic atherosclerotic lower extremity ischemia

• Kim TY
• Yun WS
• Park K

Abstract

PURPOSE
To identify the risk factors of major adverse cardiac event (MACE) in patients with chronic atherosclerotic lower extremity ischemia (CALEI) undergoing revascularization without noninvasive stress testing (NIST).
METHODS
From January 2007 to January 2012, patients with CALEI who underwent revascularization were retrospectively reviewed. Emergent operations, revision procedures for previous surgery, or patients with active cardiac conditions were excluded. NIST was not performed for patients without active cardiac conditions. Cardiac risk was categorized into low, intermediate and high risk, according to the Lee's revised cardiac risk index. MACE was defined as acute myocardial infarction or any cardiac death within 30 days after surgery.
RESULTS
A total of 459 patients underwent elective lower extremity revascularization procedures (240 open surgeries, 128 endovascular procedures, and 91 hybrid surgeries). The treated lesions comprised of 18% aorto-iliac, 58% infrainguinal, and 24% combined lesions. With regard to cardiac risk, low-, intermediate- and high risks were 67%, 32% and 2%, respectively. MACE was developed in 7 patients (2%). High or intermediate risk group by the Lee's index was related to postoperative MACE. Subgroup analysis for open surgery or hybrid surgery group identified female gender as an independent risk factor of MACE (P = 0.049; odds ratio, 5.168; confidence interval, 1.011 to 26.423).
CONCLUSION
The Lee's index was a useful predictor of MACE. MACE is more common in female patients than male patients after open or hybrid surgery. Routine preoperative NIST is not suggested for all patients undergoing revascularization for CALEI, especially for those in the low risk group.

Keyword

Peripheral arterial disease; Postoperative complications; Myocardial infarction; Risk factors

MeSH Terms

Chimera
Death
Endovascular Procedures
Exercise Test
Female
Humans
Ischemia
Lower Extremity
Male
Myocardial Infarction
Odds Ratio
Peripheral Arterial Disease
Postoperative Complications
Retrospective Studies
Risk Factors

Reference

1. L'Italien GJ, Cambria RP, Cutler BS, Leppo JA, Paul SD, Brewster DC, et al. Comparative early and late cardiac morbidity among patients requiring different vascular surgery procedures. J Vasc Surg. 1995. 21:935–944.

2. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007. 50:1707–1732.

3. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999. 100:1043–1049.

4. Campeau L. Letter: grading of angina pectoris. Circulation. 1976. 54:522–523.

5. Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001. 286:1317–1324.

6. Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, et al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006. 295:180–189.

7. Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 1996. 27:910–948.

8. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, 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). J Am Coll Cardiol. 2002. 39:542–553.

9. Poldermans D, Bax JJ, Schouten O, Neskovic AN, Paelinck B, Rocci G, et al. Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? J Am Coll Cardiol. 2006. 48:964–969.

10. McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004. 351:2795–2804.

11. Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery. European Society of Cardiology (ESC). Poldermans D, Bax JJ, Boersma E, De Hert S, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J. 2009. 30:2769–2812.

12. Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010. 152:26–35.

13. Welten GM, Schouten O, van Domburg RT, Feringa HH, Hoeks SE, Dunkelgrun M, et al. The influence of aging on the prognostic value of the revised cardiac risk index for postoperative cardiac complications in vascular surgery patients. Eur J Vasc Endovasc Surg. 2007. 34:632–638.

14. Bertges DJ, Goodney PP, Zhao Y, Schanzer A, Nolan BW, Likosky DS, et al. The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients. J Vasc Surg. 2010. 52:674–683.e3.