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CLINICAL RESEARCH: CLINICAL TRIAL

Systematic Strategy of Prophylactic Coronary Angiography Improves Long-Term Outcome After Major Vascular Surgery in Medium- to High-Risk Patients

A Prospective, Randomized Study

Mario Monaco, MD^_*, Paolo Stassano, MD, Luigi Di Tommaso, MD^,_*, Paolo Pepino, MD^_*, Arturo Giordano, MD, Giovanni B. Pinna, MD, Gabriele Iannelli, MD and Giuseppe Ambrosio, MD, PhD

^_* Unit of Cardiovascular Surgery, Istituto Clinico Pineta Grande, Castelvolturno, Italy
Interventional Cardiology, Istituto Clinico Pineta Grande, Castelvolturno, Italy
Unit of Cardiac Surgery, University "Federico II" Medical School, Naples, Italy
Division of Cardiology, University of Perugia Medical School, Perugia, Italy

Manuscript received December 29, 2008; revised manuscript received May 4, 2009, accepted May 11, 2009.

^_* Reprint requests and correspondence: Dr. Luigi Di Tommaso, 33 Via V. Gemito, Caserta 81100, Italy (Email: lditommaso{at}tin.it).

Objectives: This study was undertaken to determine the impact of a strategy of systematic coronary angiography on immediate- and long-term outcome of patients at medium-high risk who were undergoing surgical treatment of peripheral arterial disease.

Background: Despite pre-operative risk stratification according to the current guidelines, vascular surgery patients still represent a high-risk population, as 30-day cardiovascular complications and mortality rates still remain as high as 15% to 20% and 3% to 5%, respectively.

Methods: In all, 208 consecutive patients scheduled for elective surgical treatment of major vascular disease and with a revised cardiac risk index 2 were randomly allocated to either a "selective strategy" group (group A, n = 103), in whom coronary angiography was performed based on the results of noninvasive tests, or to a "systematic strategy" group (group B, n = 105), consisting of patients who systematically underwent pre-operative coronary angiography.

Results: The 2 groups were similar with respect to baseline clinical characteristics, revised cardiac risk index, and type of vascular surgery performed. The myocardial revascularization rate in group B was higher than in group A (58.1% vs. 40.1%; p = 0.01). In-hospital major adverse cardiovascular event rate was not significantly lower in group B (p = 0.07). At 58 ± 17 months of follow-up, group B showed significantly better survival (p = 0.01) and freedom from death/cardiovascular events (p = 0.003).

Conclusions: In this study, a strategy of routine coronary angiography positively impacted long-term outcome of peripheral arterial disease surgical patients at medium-high risk. This is the first such demonstration in a randomized, prospective trial. Multicenter trials to confirm this finding in a larger population are warranted.

Key Words: vascular surgery • risk stratification • coronary angiography • peripheral vascular disease • revascularization

Abbreviations and Acronyms   AAA = abdominal aortic aneurysm   ACC = American College of Cardiology   AHA = American Heart Association   CABG = coronary artery bypass graft surgery   CAD = coronary artery disease   CCS = Canadian Cardiovascular Society   DSE = dobutamine stress echocardiography   dTS = dipyridamole-thallium scintigraphy   OPCABG = off-pump coronary artery bypass graft surgery   MACE = major adverse cardiovascular event   MI = myocardial infarction   NYHA = New York Heart Association   PAD = peripheral artery disease   RCRI = revised cardiac risk index

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