Cardiopulmonary Assessment for Major Vascular Reconstructive Procedures

Abstract

function is essential in the planning of major arterial reconstructive surgery. In fact, recognition and treatment of underlying cardiac or pulmonary disease may be of greater importance in some patients than the performance of the vascular surgical procedure itself. Additionally, the preoperative evaluation affords an opportunity for the physician to institute risk factor modification that may be of particular benefit in this high-risk patient pool. Coronary artery disease causes many, if not the majority, of immediate and late postoperative deaths following peripheral vascular surgical procedures. Although the role of impaired pulmonary function in contributing to operative mortality with peripheral vascular procedures is not as well defined as is cardiac disease, postoperative morbidity attributed to severe pulmonary disease is well recognized. Coronary artery disease is clearly an important factor in determining the eventual outcome of vascular reconstructions in many patients. For example, cardiac complications after carotid endarterectomy, abdominal aortic aneurysm resection, and lower extremity revascularization at the Cleveland Clinic were responsible for 43% of early deaths, and fatal myocardial infarctions occurred in 20% of the survivors during an 8-year period of follow-up (1). In this later experience, 5and 10-year actuarial survivals were 82% and 49%, respectively, among patients without antecedent indications of coronary artery disease, compared with 67% and 31% at these same time points among those suspected of having coronary artery disease. Myocardial infarction at this same institution accounted for 37% of early postoperative deaths among 343 patients undergoing operations for abdominal aortic aneurysm and 52% of early postoperative deaths among 273 undergoing operations for lower extremity ischemia (2,3). Others have encountered similar mortality and morbidity rates, a clear reflection that patients with peripheral vascular disease often have coexistent lifethreatening coronary artery disease (4), and the risk of cardiac events appears to be as great during vascular reconstructions for severe infrainguinal vascular disease as for aortic disease (5).