Evaluation and surgical management of patients with severe combined coronary artery disease and peripheral vascular atherosclerosis

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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, . . .



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