Peripheral Repair Can Come First in Advanced CAD Patients

By Janice Rosenberg

CHICAGO -- Patients with advanced coronary artery disease and either threatened limb loss or claudication can undergo major vascular operations with low mortality and morbidity without prior coronary revascularization, according to data reported by Amritha Raghunathan, M.D., at the Vascular Annual Meeting.

"The threatened-limb-loss patients were older and more had diabetes and prior stroke than those with claudication," said Dr. Raghunathan of the San Francisco Veterans Affairs Medical Center. "They had one-, two-, and three-vessel disease."

Investigators used the Coronary Artery Revascularization Prophylaxis (CARP) trial database to determine whether cardiac revascularization prior to elective vascular surgery would decrease mortality and morbidity over the long term (2.7 years) and perioperatively (30 days).

The study design was a subanalysis of the CARP trial, a prospective, randomized 18-center trial sponsored by the cooperative studies program of the Department of Veterans Affairs.

For this research, 510 preoperative vascular patients with severe coronary artery disease, all male, who were enrolled in the CARP trial were randomized to coronary revascularization or no revascularization prior to surgery for peripheral vascular disease.

The indications for peripheral revascularization were threatened limb loss in 152 patients and claudication in 189 patients. The extent of coronary artery disease was determined by cardiac catheterization. All patients had at least 70% stenosis.

Half of the peripheral revascularization patients in the study underwent heart surgery first. The patients with claudication had more abdominal operations and longer hospital stays.

The claudication group had more perioperative myocardial infarctions, although perioperative mortality was similar in the two groups. In follow-up, the claudication group also had numerically more myocardial infarctions, but mortality was not different.

Those patients diagnosed with threatened limb loss had more urgent operations, reoperations, and limb loss.

Results showed that perioperative outcomes are not affected by cardiac revascularization in patients with either threatened limb loss or claudication.

It was postulated that the better-than-predicted outcomes for these high-risk patients may be due to the use of aggressive preoperative care and intense medical management with b-blockers, statins, ACE inhibitors, and aspirin.

During the discussion that followed the talk, Joseph H. Rapp, M.D., said that complete revascularization of the heart is a myth.

"Small vessels that are occluded can't be done. Some are so narrow they can't be bypassed. So I've learned from this study that the idea that we can protect these patients surgically is a myth. We need another paradigm to prevent their cardiac mortality," said Dr. Rapp, a surgeon at the University of California, San Francisco, and one of the site directors for the CARP trial.

Nevertheless, outcomes for these patients were very good, relatively speaking, said Dr. Rapp in an interview.

"These are patients with 70% coronary lesions. Normally, you'd advise them to write their wills. At 2.7 years, 23% were dead, but for this kind of disease and that kind of coronary anatomy, that's a pretty good outcome. We think it's because they were being treated aggressively with b-blockers and statins," he said.

PERIOPERATIVE OUTCOMES ARE NOT AFFECTED BY CARDIAC REVASCULARIZATION IN PATIENTS WITH EITHER THREATENED LIMB LOSS OR CLAUDICATION.