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J Am Coll Cardiol, 2007; 50:1398-1399, doi:10.1016/j.jacc.2007.06.032 (Published online 14 September 2007).
© 2007 by the American College of Cardiology Foundation
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CORRESPONDENCE: LETTER TO THE EDITOR

High-Risk Patients Undergoing Major Vascular Surgery: To Operate or Not to Operate?

André Coelho Marques, MD, Pai Ching Yu, MD, Daniela Calderaro, MD, Danielle Menosi Gualandro, MD and Bruno Caramelli, MD, PhD*

* Heart Institute, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44 Cerqueira César, CEP 05403-000 Bloco II—andar AB UMIC, São Paulo, Brazil (Email: bcaramel{at}usp.br).

Poldermans et al. (1) described the effects of preoperative coronary revascularization in high-risk patients undergoing major vascular surgery. The first randomized study analyzing the value of this strategy was the CARP (Coronary Artery Revascularization Prophylaxis) trial (2), which did not show any advantage in performing myocardial revascularization before vascular surgery in stable patients. Nevertheless, the elevated prevalence of low-risk patients in the CARP trial could have influenced the final results. The DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo)-V pilot study was designed to test the efficacy of different treatment strategies—myocardial revascularization and clinical treatment—in reducing perioperative complications in high-risk patients undergoing major vascular surgery. The fact that both strategies were associated to similar rates of perioperative complications led the authors to suggest that screening tests may become unnecessary. We argue with Poldermans et al. (1) thus: the DECREASE-V pilot study showed a high rate of events in both groups, regardless of treatment strategies. The revascularization group had 42.9% of events in the short term and 49% in long term, whereas the no-revascularization group had 32.7% of events in short-term and 44.2% in long-term follow-up. These findings reflect the groups of patients’ profiles, with multiple cardiac risk factors and extensive stress-induced myocardial ischemia. We think that it would be important to know the event rates in a group not receiving surgical intervention. Indeed, the rate of vascular complications in patients who do not undergo surgical procedures is lower than that observed by Poldermans et al. (1). Abdominal aortic aneurysms have annual rupture rates in the range of 4%, 7%, and 20% for diameters of 5.0, 6.0, and 7.0 cm, respectively. In patients with lower-extremity peripheral arterial disease and claudication, the progression rate to limb ischemia is about 1% to 2% in 5 years, and worsening claudication will come in 10% to 20% of patients in the same period (3). The advances in surgical technique were notable and now allow procedures in a broader population including high-risk patients. Therefore, there has been a steep increase in the number of major surgical procedures performed in these high-risk patients, raising the perioperative cardiovascular event rates. An individual approach should be recommended to this specific group, and physicians and patients must be aware of the risks and benefits of performing major surgery in this situation. The optimal perioperative management of patients with extensive coronary artery disease remains unknown. Poldermans et al. (1) should be congratulated on completing this pilot study, but we suggest that for future studies in this area a third group (no surgery) should be evaluated. The "no surgery" option should always be discussed and offered to this extremely high-risk population, until we are able to overcome the current limitations of contemporary medicine.


   References
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  1. Poldermans D, Schouten O, Vidakovic R, et al. DECREASE Study Group A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V pilot study J Am Coll Cardiol 2007;49:1763-1769.[Abstract/Free Full Text]
  2. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery N Engl J Med 2004;351:2795-2804.[Abstract/Free Full Text]
  3. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) Circulation 2006;113:e463-e654.[Free Full Text]




This Article
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