Background: The objective of the study was to estimate, on the basis of the authors’ experience, the importance of cardiological diagnostics for the efficacious risk stratification of perioperative cardiac complications in vascular surgery.
Material and methods: Since 2002 we evaluated the usefulness of a coronary angiography before elective surgical procedures in patients with abdominal aortic aneurysm (AAA). 132 patients, 42-79 years old, were enrolled in the study. A coronary angiography was performed in 50 patients (38%) with angina classified higher than group I according to Canadian Cardiological Society criteria.
In 2005 we extended noninvasive testing of coronary artery disease with a dobutamine stress echocardiography (DSE) in patients with exercise angina classified as CCS II. The study was conducted in 30 patients, 57-75 years old, prepared for major vascular surgery. The same year we introduced the six-minute walk test into noninvasive cardologic diagnostics in patients with chronic lower extremities ischaemia. The study was performed in 57 patients with chronic lower limb ischaemia, 47-81 years old, in whom the intermittent claudication distance and maximum distance were measured. Simultaneously, blood pressure values and rest and post-exercise ECG records were analyzed. The particular distances were linked with the results of peripheral vessels angiography. The cardiological diagnostics model has been established on the strength of the authors’ personal studies presented above.
Results: On the basis of coronary angiography results, myocardial revascularization prior to surgical treatment of an AAA was performed in 36 patients (27.2%), including percutaneous transluminal coronary angioplasty (PTCA) in 23 patients (17.3%) and coronary artery bypass grafting (CABG) in 13 patients (9.8%). In qualification for AAA treatment, the value of left ventricular ejection fraction was taken into consideration. Patients with an ejection fraction higher than 45% were referred for the traditional AAA treatment, patients with EF < 45% for endovascular procedures and patients with EF < 35% for AAA banding. The established management pattern caused that the mortality rate in the studied group was 5.5%, and 2.17% in elective AAA treatment procedures.
Dobutamine stress echocardiography results: 17 patients with negative DSE tests were referred directly for surgical treatment of AAA and 13 patients with positive DSE tests for coronary angiography (group of high-risk vascular surgery).
6-minute walk test results: in the group of 51 patients with chronic lower extremities ischaemia chest pain occured in only 1 patient after 200 meters of walking. The test was interrupted and in the ECG record, a myocardial ischaemia was observed. In the first stage, the patient was referred for a coronary angiography (a patient with a high risk of cardiac complications).
Conclusions: DSE and 6MWT enables one to distinguish patients with a high risk of cardiac complications before major vascular surgery. Subsequent myocardial revascularization in patients with severe lesions occluding coronary vessels, considerably reduces the perioperative mortality of vascular surgery.