Published online Oct 26, 2014. doi: 10.4330/wjc.v6.i10.1100
Revised: March 6, 2014
Accepted: September 16, 2014
Published online: October 26, 2014
Cardiovascular disease is the leading cause of death in patients with peripheral arterial disease (PAD). Coronary artery disease (CAD) is highly prevalent, and often times coexist, in patients with PAD. The management of patients with PAD that requires a high-risk vascular surgical procedure for intermittent claudication, critical limb ischemia or expanding abdominal aortic aneurysm requires risk stratification with the revised cardiac risk index, optimization of medical therapies, and limited use of cardiac imaging prior to surgery. Preventive revascularization in patients with stable CAD, with the sole intention to mitigate the risk of cardiac complications in the peri-operative period, is not effective and may be associated with significant bleeding and thrombotic risks, in particular if stents are used. A strategy of universal use of cardiac troponins in the perioperative period for active surveillance of myocardial ischemia may be more reasonable and cost-effective than the current standard of care of widespread use of cardiac imaging prior to high-risk surgery. An elevated cardiac troponin after vascular surgery is predictive of long-term mortality risk. Medical therapies such as aspirin and statins are recommended for patients with post-operative myocardial ischemia. Ongoing trials are assessing the role of novel anticoagulants. Additional research is needed to define the role of cardiac imaging and invasive angiography in this population.
Core tip: Patients with advanced peripheral arterial disease who need vascular surgery have a high prevalence of coronary atherosclerosis and are at increased risk of perioperative myocardial infarction. Coronary revascularization prior to the vascular operation is not an effective intervention to mitigate this risk. A strategy of widespread use of cardiac troponins in the perioperative period is recommended to detect perioperative ischemic events associated with a long-term mortality risk. The selective use of medical interventions, cardiac imaging and coronary angiography in this population deserves further study.