Management of the vascular patient with multisystem atherosclerosis

Abstract

HE NUMBER OF patients undergoing vascular evaluations and subsequent vascular surgical procedures has risen dramatically during the last decade. We have attributed this rise to a better understanding of the natural history of the various forms of vascular disease, increasingly sophisticated diagnostic facilities, and improved surgical expertise. Many of these vascular patients have significant coexistent coronary artery disease (CAD) that can determine immediate as well as longterm postoperative outcomes. Indeed, though a patient’s quality of life may be improved by the vascular procedure alone, the management of the coexistent CAD may ultimately play a larger part in determining the longevity of the patient. It is essential that physicians who treat peripheral vascular patients be aware of the factors leading to the development of peripheral vascular disease, appropriate medical and surgical interventions, and associated risks and benefits. The treating physician must recognize the need to uncover and effectively establish the diagnosis and extent of coexistent CAD. This information then serves as a basis for determining appropriate management strategies for individual patients with isolated peripheral vascular disease and those with combined peripheral vascular and coronary artery disease. In subsequent sections, we will review the incidence, pathogenesis, diagnostic features, and therapeutic measures for three of the most common forms of vascular disease: (1) cerebrovascular insufficiency, (2) abdominal aortic aneurysm (AAA), and (3) ~ripheral vascular occlusive disease (PVD). We will review data that are used to establish guidelines for determining the presence and extent of CAD. In addition, we will discuss how these data are used in management decisions regarding vascular patients with minimal, moderate, and extensive CAD.