Combined coronary artery and peripheral vascular disease: Recognition and treatment

Abstract

It is now well established that arteriosclerotic or atherosclerotic occlusive disease tends to assume distinctive anatomic, pathologic, and clinical patterns in the four major arterial beds of the body, namely, the coronary arterial bed, the major branches of the aortic arch, the visceral branches of the abdominal aorta, and the terminal abdominal aorta and its major branches. 1 It is also now well recognized that the occlusive process may occur in more than one ofthese arterial beds simultaneously or serially over a period of time. Of particular significance in this connection is the need to recognize the occurrence of the disease in the coronary arterial bed with or without overt signs and symptoms in patients whose primary clinical manifestations are caused by occlusion in the other arterial beds. The frequency of these combined patterns of occlusive disease and ~ e value of proper recognition and treatment deserve emphasis. The excessive mortality rate among patients with peripheral vascular disease as compared with the rate for the general United States population 2-4 !s associated with cardiac conditions, about one-half of all deaths being related to acute myocardial infarction. Similarly, when patients with cardiac conditions are operated on for peripheral vascular disease, about half of the perioperative mortality rate is related to acute myocardial infarction. 5-7 The importance of identifying preoperatively those patients considered high surgical risks because of atherosclerotic coronary arteries therefore cannot be overemphasized. Clinical factors predictive of risk of cardiac death in the perioperative and late postoperative period, identified in a number of studies, 5-9 include: age at operation; history of heart failure, angina pectoris, or myocardial infarction; abnormal result of resting electrocardiography (old infarction, ischemia, or arrhythmia); history of stroke; other associated vascu-