Evaluation and surgical management of patients with severe combined coronary artery disease and peripheral vascular atherosclerosis
Retrospective analysis of our experience and the results from other centers indicate that development of a myocardial infarction contributes substantially to both early and late mortality in patients undergoing major peripheral vascular surgery. After abdominal aneurysmectomy, hospital mortality ranged from 8% to 10% and the 5- and 10-year attrition rates were from 40% to 72%. In aortofemoral bypass patients, the operative mortality rate was 4% to 5% with a late mortality rate from 31% t o 91%. More than 50% of late deaths were cardiac related. These data clearly indicate that a new approach to evaluation and treatment was required.
Beginning in April 1978, all potential candidates for major peripheral vascular surgical procedures underwent selective coronary arteriography (risk 0.03% at The Cleveland Clinic Foundation) regardless of whether coronary atherosclerosis was suspected. Based on the arteriographic findings, the patients were divided into three subsets: those with mild or stable coronary artery disease (CAD), severe but operable CAD, and severe diffuse inoperable CAD. A further division of the first 181 consecutive patients so evaluated into CAD suspected group (68) and unsuspected group (113) revealed that of the suspected group, 28 (41%) had mild or compensated CAD, 25 patients (37%) had severe but operable CAD, and 15 (22%) were inoperable. In the CAD unsuspected group, 87 (77%) had insignificant CAD, but 22 patients (19%) had severe and operable CAD with four (4%) in the diffuse inoperable group. Division of patients who exhibit signs or symptoms of CAD into aneurysm, carotid and aortoiliac subgroups, . . .