Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 231-234

Association of coronary artery disease and peripheral arterial disease in patients undergoing elective open abdominal aortic aneurysm repair


Department of CVTS, Division of Vascular Surgery, SCTIMST, Thiruvananthapuram, Kerala, India

Date of Submission07-Jan-2019
Date of Decision15-Mar-2019
Date of Acceptance18-Mar-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Sreekumar Ramachandran
Department of CVTS, Division of Vascular Surgery, SCTIMST, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_2_19

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  Abstract 


Introduction: Open surgical repair of abdominal aortic aneurysm (AAA) is one of the commonest aortic surgeries performed in tertiary care vascular centres. As association of coronary artery disease (CAD) and peripheral arterial disease (PAD) is high in these patients, need for cardiac risk stratification with or without coronary intervention prior to surgery and its effect on long term survival benefit have been debated. In our institution, all patients who undergo elective aortic aneurysm surgery undergo diagnostic coronary angiogram. Intervention (Percutaneous Coronary Intervention or coronary artery bypass surgery) was performed prior to surgery, if patient was symptomatic/ had multiple critical occlusions in coronary vessels. We also looked into the prevalence of peripheral arterial disease in these patients. Methods: Single centre retrospective study. 199 patients who underwent elective aortic aneurysm repair in the last 10 years were studied. Data was collected from electronic and hospital medical records and analysed. Results: Significant CAD was seen in 105 patients (52.7%) out of which 40 patients (20.1%) underwent preoperative intervention while 65 patients (32.7%) underwent surgery without the same. Prevalence of significant CAD in AAA was high (52.7%) whereas PAD was seen in 26 patients (13.1%). Conclusion: We suggest it worthwhile to assess the coronary status in these patients preoperatively for risk stratification. Prophylactic coronary revascularization should be individualized and can prevent post-operative adverse cardiac events. Medical treatment for concomitant CAD with no obvious inducible ischemia does not confer unfavorable outcomes. Presence of PAD should not be overlooked and should be identified and intervened in the same setting if critical to decrease the morbidity.

Keywords: Abdominal aortic aneurysm, coronary artery disease, peripheral arterial disease


How to cite this article:
Nair HR, Pitchai S, Vineethkumar P M, Goura P, Ramachandran S. Association of coronary artery disease and peripheral arterial disease in patients undergoing elective open abdominal aortic aneurysm repair. Indian J Vasc Endovasc Surg 2019;6:231-4

How to cite this URL:
Nair HR, Pitchai S, Vineethkumar P M, Goura P, Ramachandran S. Association of coronary artery disease and peripheral arterial disease in patients undergoing elective open abdominal aortic aneurysm repair. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Dec 3];6:231-4. Available from: https://www.indjvascsurg.org/text.asp?2019/6/4/231/273588




  Introduction Top


Open surgical repair of abdominal aortic aneurysm (AAA) with aortic graft was first performed by Dubost in 1951, but Creech in 1966 familiarized the endoaneurysmorrhaphy technique as being practiced today.[1] Since then, the morbidity and mortality associated with open surgery have drastically improved owing to better preoperative optimization of patients and excellent perioperative care. Although endovascular aneurysm repair (EVAR) reduces the morbidity considerably, open surgical repair continues to be the gold standard in fit patients.

The assessment of cardiac status with risk stratification has been discussed ever since to reduce cardiac morbidity. The need for routine preoperative coronary revascularization has been a matter of debate, as although the cardiac-specific survival rate improves in the perioperative period, it was not significant as compared to medical management alone.[2] The fact that AAA is associated with other diseases with similar risk factors is well documented. Coronary artery disease (CAD) is the most common association, being present in up to 60% of patients and the cause for perioperative mortality in these patients. Peripheral arterial disease (PAD) also coexists in these patients and may be asymptomatic or masked due to more significant symptoms of aneurysm. There is wide literature studying the incidence of AAA and/or PAD in CAD patients, but the information regarding the association of CAD/PAD in AAA patients remains limited. The purpose of this study was to assess the incidence of CAD and PAD in patients undergoing elective AAA repair.


  Patients and Methods Top


A total of 199 patients who underwent elective open abdominal (infrarenal and juxtarenal) aortic aneurysm repair from January 2008 to December 2017 (10 years) were included in the study.

This was a single-center retrospective study. Patients who underwent emergency repair of ruptured aortic aneurysm, suprarenal aneurysms, and those who underwent EVAR were excluded from the study. Patients who underwent aortic revascularization procedure (incidental aortic aneurysm with iliofemoral occlusion) were also not included in the study as they were considered as trans-atlantic inter-society consensus D (TASC-D) aortoiliac disease.

All the patients underwent preoperative coronary angiogram (CAG) either conventional or computed tomography (CT) CAG as an institutional protocol, except if they already had a history of CAD and underwent prior intervention in the past 5 years and were asymptomatic.[3]

Perioperative adverse cardiac event was defined as elevated cardiac biomarkers[4] (Troponin T and serum-CKMB), along with any one of the following:

  1. Symptoms of myocardial ischemia/new-onset pulmonary edema
  2. Electrocardiographic evidence of ischemia-pathologic Q-waves, ST-T wave changes, or new left bundle branch block
  3. Echocardiogram showing loss of viable myocardium or a new abnormal left ventricular (LV) wall motion.


PAD was identified as the presence of lower limb arterial disease, which was incidentally detected and whether the patient was symptomatic in the form of claudication or critical limb ischemia based on the Ankle–Brachial Pressure Index (ABI <0.9) and tissue loss.

Data were collected from the patient's hospital records and electronic medical records. Statistical analysis was done using the Chi-square test, log-rank test, and Kaplan–Meyer survival analysis. All data analysis was done using SPSS-16 statistical analysis software.


  Results Top


The total number of patients who underwent open AAA repair was 199. The mean age of the patient cohort was 64.9 years, with a predominant male population (93.5%) and male: female ratio of 12.75:1. The mean size of the aneurysm was 6.8 cm (range, from 4.0 to 14 cm, standard deviation = 1.7).

186 patients (93.5%) had hypertension, while 31 (15.6%) had type-2 diabetes mellitus. Most of the patients (171 patients 85.9%) were smokers (active or recently quit).

A total of 165 patients underwent CAG – 151 conventional and 14 CT CAG. Thirty-four patients had undergone coronary revascularization in the past 5 years and asymptomatic for the same [Figure 1]. The CAG findings were divided into five groups for risk stratification – normal CAG, mild/minor disease (minor plaques and stenosis <50%), significant single-vessel disease >50%, double-vessel disease (DVD), and triple-vessel disease (TVD) [Table 1].[4],[5] The overall incidence of significant CAD with critical single-vessel disease/DVD/TVD was seen in 105 patients (52.7%). About 40 patients in this group underwent either PCI or coronary artery bypass grafting (CABG) before aneurysm surgery (36 underwent PCI and 4 underwent CABG), while 65 underwent surgery without prior revascularization.
Figure 1: Coronary angiogram status

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Table 1: Coronary artery disease severity with respect to coronary angiogram findings

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Three patients (out of 4) underwent concomitant CABG with aneurysm repair. One patient underwent off-pump CABG, whereas others underwent on-pump CABG. In this subset, CABG was performed first, followed by aneurysm repair.

A total of 19 patients had cardiac morbidity in the immediate postoperative period in the form of arrhythmias, non-ST-segment elevation myocardial infarction, and cardiac failure but were successfully managed conservatively; 2 out of 19 had undergone concomitant CABG, 1 had undergone preoperative PCI, and 16 had not undergone coronary revascularization. Four patients died in the perioperative period with one dying of cardiac cause, while four patients had long-term mortality due to cardiac causes. The overall mortality was 18 (9%) in the study group [Table 2].
Table 2: Coronary status and cardiac complications

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Twenty-six patients (13.1%) had PAD of varying degrees of severity. Eleven out of these 26 patients were having mild intermittent claudication with infrapopliteal arterial disease. Nine patients had disabling claudication (ABI 0.5–0.8). Six patients had incidentally detected PAD and were not symptomatic. Five patients had atheroembolism in the postoperative period with cyanosis of toes and were successfully managed with anticoagulation (up to 3 months) alone. All 5 patients had complete disappearance of symptoms by 3-4 weeks. We noticed that 16 of 26 patients (all 9 in disabling claudication group and 7 in mild claudication) had significant improvement in their symptoms during follow-up [Figure 2].
Figure 2: Severity of peripheral arterial disease

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  Discussion Top


Open repair has stood the test of time and is considered the gold standard for the treatment of AAA. The open surgery has come a long way with excellent survival rates owing to better pre- and peri-operative optimization of patients. The perioperative morbidity and long-term mortality of open aortic aneurysm surgery are still accounted by cardiac causes. This was the basis for subjecting patients to routine preoperative coronary imaging with or without revascularization, which is still a matter of debate.[5],[6]

One of the earliest studies was done by Hertzer et al. retrospectively in 1522 patients, where he found that 81% of the patients with postoperative MI or cardiac death had at least one total coronary artery occlusion with collaterals compared with 29% in match-controlled patients without cardiac complications.[5] In every other respect, patients with postoperative complications also had more severe CAD prior to surgery as compared with the control group. In their cohort, 68% of preoperative patients had minimal or no clinically significant angiographic findings (<70% disease). Among patients with significant coronary stenosis, there was a spectrum of single- (46%), double- (33%), and triple (21%)-vessel diseases.[3] Our study cohort also had a high incidence of clinically significant CAD (52.7%).

Similarly, Suggs et al. found that among the 247 AAA repairs performed, there were three perioperative deaths (1.2%), all of which resulted from sudden cardiac events; three additional patients had nonfatal myocardial infarctions (1.2%), for a total cardiac complication rate of 2.4%.[7] The low rate of cardiac complications in this experience affirms the effectiveness of preoperative screening and selective coronary revascularization before AAA repair. In this study, one patient who died in the perioperative period had severe CAD, but surgery was performed without prior revascularization as he was symptomatic with large aneurysm size.

As a matter of protocol, our institution routinely performs conventional or CT CAG for all patients undergoing elective aortic aneurysm repair surgery. Those patients who have a history of CAD and underwent CABG/PCI in the last 5 years, with no evidence of myocardial insufficiency will not undergo further coronary imaging as per the findings in the Coronary Artery Revascularization Prophylaxis (CARP) trial and the American College of Cardiology recommendations.[6] However, the limitations of CARP trial were striking in that only a minority of the patients had evidence of severe ischemia on noninvasive testing, and the study was underpowered to assess this key aspect. It also excluded significant left anterior descending artery disease and severe LV dysfunction. Later, studies based on CARP and registry data, however, revealed that the long-term survival benefit was achieved with preoperative coronary revascularization.[8],[7]

Monaco et al. with systematic strategy discovered 50% more patients with significant CAD than the selective strategy and had more subsequent coronary revascularizations (58% vs. 40%, respectively) and was associated with significantly better long-term survival and freedom from major adverse cardiac events.[8] Mangano et al. found that in high-risk patients undergoing noncardiac surgery, early postoperative myocardial ischemia is an important correlate of adverse cardiac outcomes.[9] Sixteen out of 19 patients had postoperative cardiac morbidity although not fatal. Ruddy et al. found that either staged or concomitant CABG and AAA repair may be viable options when minimally invasive interventions are not feasible.[10] In light of this, it is of no debate that, preoperative coronary imaging definitely aids in proper risk stratification and anticipation of possible perioperative cardiac events.

Even less commonly performed is concomitant CABG with AAA repair. We performed simultaneous CABG and AAA repair in three patients while one patient underwent AAA repair after 1 month of CABG. Long-term survival of these patients is awaited. Ascione et al. published their experience with the same and has been documented to be safe.[11] Takahashi et al. did a study similar to ours with similar sample size and found that the incidence of patients who required CABG in the treatment of AAA was 4.4% and that the results may justify the routine enforcement of preoperative CAG in patients with AAA.[12]

The studies pertaining to the prevalence of PAD in AAA are limited, although it is an entity that is overlooked or masked due to the more serious coexisting aneurysm. Leong et al. found that there was a significant association of PAD and AAA in patients admitted with acute coronary syndrome. We found that majority of the patients had symptomatic relief of PAD postaneurysm repair, although they need to be followed up routinely.[13]


  Conclusion Top


Based on our results, we suggest that it is worthwhile to perform routine coronary imaging for optimal risk stratification prior to surgery, and revascularization should be performed based on individual patient characteristics to prevent adverse cardiac events. We also found that, if facilities permit, concomitant CABG with AAA repair is a novel technique that can be safely performed in fit patients in whom PCI is not feasible. The presence of PAD should be identified and documented promptly in these patients with close follow-up.

Acknowledgment

The authors would like to place on record their gratitude to Prof. Asha Kishore, the Director of the Institute, for her permission to publish our work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: Reestablishment of the continuity by a preserved human arterial graft, with result after five months. AMA Arch Surg 1952;64:405-8.  Back to cited text no. 1
    
2.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol 2012;60:1581-98.  Back to cited text no. 2
    
3.
Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An update of the 2011 ACCF/AHA/SCAI guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation 2016;134:e123-55.  Back to cited text no. 3
    
4.
Yamagishi M, Hosokawa H, Saito S, Kanemitsu S, Chino M, Koyanagi S, et al. Coronary disease morphology and distribution determined by quantitative angiography and intravascular ultrasound – Re-evaluation in a cooperative multicenter intravascular ultrasound study (COMIUS). Circ J 2002;66:735-40.  Back to cited text no. 4
    
5.
Young JR, Hertzer NR, Beven EG, Ruschhaupt WF 3rd, Graor RA, O'Hara PJ, et al. Coronary artery disease in patients with aortic aneurysm: A classification of 302 coronary angiograms and results of surgical management. Ann Vasc Surg 1986;1:36-42.  Back to cited text no. 5
    
6.
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;351:2795-804.  Back to cited text no. 6
    
7.
Suggs WD, Smith RB 3rd, Weintraub WS, Dodson TF, Salam AA, Motta JC, et al. Selective screening for coronary artery disease in patients undergoing elective repair of abdominal aortic aneurysms. J Vasc Surg 1993;18:349-55.  Back to cited text no. 7
    
8.
Monaco M, Stassano P, Di Tommaso L, Pepino P, Giordano A, Pinna GB, et al. Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in medium- to high-risk patients: A prospective, randomized study. J Am Coll Cardiol 2009;54:989-96.  Back to cited text no. 8
    
9.
Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo IM, et al. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The study of perioperative ischemia research group. N Engl J Med 1990;323:1781-8.  Back to cited text no. 9
    
10.
Ruddy JM, Yarbrough W, Brothers T, Robison J, Elliott B. Abdominal aortic aneurysm and significant coronary artery disease: Strategies and options. South Med J 2008;101:1113-6.  Back to cited text no. 10
    
11.
Ascione R, Iannelli G, Lim KH, Imura H, Spampinato N. One-stage coronary and abdominal aortic operation with or without cardiopulmonary bypass: Early and midterm follow-up. Ann Thorac Surg 2001;72:768-74.  Back to cited text no. 11
    
12.
Takahashi J, Okude J, Gohda T, Murakami T, Hatakeyama M, Sasaki S, et al. Coronary artery bypass surgery in patients with abdominal aortic aneurysm: Detection and treatment of concomitant coronary artery disease. Ann Thorac Cardiovasc Surg 2002;8:213-9.  Back to cited text no. 12
    
13.
Leong BD, Ariffin AZ, Chuah JA, Voo SY. Prevalence of peripheral arterial disease and abdominal aortic aneurysm among patients with acute coronary syndrome. Med J Malaysia 2013;68:10-2.  Back to cited text no. 13
    


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