Combined Treatment of Coronary Plus Other Arterial Pathologies the Magnitude of the Polyatherosclerotic Patient

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2.8.1 Introduction

Atherosclerosis is a generalized disease [2, 4, 9, 11, 21, 22, 41]. Therefore, it is of no surprise that simultaneous atherosclerotic lesions may exist in the carotid arteries, the coronary arteries, the aorta and the peripheral arteries in the form of unifocal, bifocal and multifocal occlusive or aneurysmal disease [1, 14, 15, 18, 26, 38, 39]. Coexistence of severe coronary artery disease with carotid artery stenosis, aortic aneurysm and critical limb ischaemia is a frequent event and the management of these patients is still unclear and in some cases controversial [12, 16, 17, 24, 27, 31, 32, 36, 37]. Therefore, multifocal atherosclerosis remains a challenge for the cardiothoracic and vascular surgeon who has, nowadays, the therapeutic alternative of open or endovascular repair.

2.8.2 The Magnitude of Multifocal Arterial Disease

In order to identify the magnitude of multifocal atherosclerosis, a study on 387 consecutive patients admitted for arterial operation was carried out by the team of The Cardiovascular and Thoracic Unit of the Nicosia General Hospital, Cyprus. The aim of this study was to calculate the percentage of modification of the surgical or endovas-cular reconstruction initially planned and, also, to demonstrate the way in which endovascular techniques have affected the management of polyatherosclerotic patients with multifocal occlusive or aneurysmal disease. Material and Methods

• Symptomatic carotid artery stenosis - 74 patients.

• Severe coronary artery disease - 198 patients.

• Thoracic aortic aneurysms - 10 patients.

• Abdominal aortic aneurysms - 55 patients.

• Severe peripheral arterial disease - 60 patients.

Preoperative evaluation included noninvasive assessment, calculation of a five-step cumulative illness scale and angiography in the form of digital subtraction, spiral CT, or

MR angiography. Noninvasive assessment utilized:

• Carotid Duplex scan, to show the site and extent of stenosis and type of atherosclerotic plaque

• ECG, to demonstrate ischaemic changes and changes in cardiac rhythm.

Treadmill exercise test, to show changes that may occur in the coronary or the peripheral circulation during exercise.

• Thallium perfusion scan, to detect myocardial isch-aemia at rest or after exercise.

• Muga scan, to investigate the pumping efficiency of the heart.

• Segmental pressure measurements using Doppler ultrasound and cuffs.

• Coloured Duplex scan, to perceive the anatomical outlook of the aorta and the peripheral arteries as well as the spectrum of blood flow at any site of stenosis.

Finally, the five steps of the cumulative illness scale were:

1 for normal

2 for mild problems

3 for moderate problems

4 for severe problems

5 for life-threatening impairment. Results

Patients were classified in five groups according to their initial diagnosis:

The overall incidence of multifocal arterial disease was 61.9% (Fig. 2.8.1).

Multifocal: 61.9% CAROTID+PAD: 13.2% CAD+PAD: 44.9%

Fig. 2.8.1 Patients with multifocal and unifocal arterial disease Fig. 2.8.2 Patients with multifocal arterial disease

Multifocal: 61.9% CAROTID+PAD: 13.2% CAD+PAD: 44.9%

Fig. 2.8.1 Patients with multifocal and unifocal arterial disease Fig. 2.8.2 Patients with multifocal arterial disease

Fig. 2.8.3 Severe multifocal arterial disease

Fig. 2.8.4 Five-step cumulative illness scale in patients with multifocal and unifocal atherosclerosis

The distribution location of multifocal arterial disease is shown in Fig. 2.8.2:

• 44.9% of multi-atherosclerotic patients had severe combined coronary and peripheral arterial disease

• 30.8% combined carotid and coronary

• 13.2% combined carotid and peripheral arterial disease

• 11.3% combined carotid, coronary and peripheral arterial disease.

Severe forms of multifocal arterial disease represented 9.5% of the total (Fig. 2.8.3).

The five-step cumulative illness scale showed that cardiovascular, respiratory and renal problems, as well as hypertension and diabetes mellitus were significantly increased in multifocal compared to unifocal disease (Fig. 2.8.4).

These results agree with those published throughout the world [4, 5, 7, 11, 16, 20, 23, 24, 29, 41].

The main focus of the study was the need to modify the initially planned treatment as a result of other vascular priorities; this proved to be necessary mainly in patients with critical limb ischaemia, as a result of severe peripheral arterial disease; 9.4% of these patients' plans were in need of modification, in the sense that the coexistence of carotid and coronary artery disease affected the initially planned treatment, altering the priorities. The results demonstrated that endovascular treatment was the first treatment of choice for patients with critical limb isch-aemia due to aorto-iliac disease. The endovascular procedures carried out showed an 85% immediate success rate. The 3-year primary patency rate was 53% for angioplasty alone and 62% for angioplasty and stenting. Surgical treatment for severe aorto-iliac disease, leading to critical limb ischaemia, was performed simultaneously with carotid endarterectomy whenever endovascular treatment was technically impossible. Endovascular treatment was

2.8.3 Multifocal Occlusive and Aneurysmal Arterial Disease

also carried out for infra-inguinal arterial disease causing critical limb ischaemia. The results showed a 75% initial success rate for superficial femoral artery occlusion and 61% for popliteal occlusion. The 1-year patency rate for both locations decreased to approximately 44%, while the 3-year patency rate was even worse, decreasing to about 28% for both locations. Endovascular reconstruction was not introduced for infra-popliteal lesions; instead, a long femoro crural by-pass graft was preferred, using either vein - when available - or a composite graft. The initial success rate was 69%; the 1-year patency rate was 58% and the 3-year patency rate 51%. In these patients other existing factors were always taken into consideration, such as sepsis, neuropathy and the presence of chronic renal and venous disease. Results demonstrated that in patients with aortic aneurysms the need to modify the initially planned treatment as a result of other vascular priorities was 1.2%; in such cases, the treatment of choice was endovascular repair of the abdominal aortic aneurysm (EVAR); general anaesthesia over local was preferred, as was the use of self-expandable grafts. The immediate and late results were free of complications, but it should be clearly noted that EVAR was used in highly selected cases. Reviews of the international literature indicate that EVAR was applied in about 4% of cases. Finally, the need for modification was similarly low (3.3%) in patients with severe symptomatic carotid and coronary artery disease, but this will be discussed further on [3, 13, 33-35, 43, 46].

The results of the study demonstrate that the coexistence of severe carotid, coronary and peripheral arterial disease is particularly high in vascular patients admitted to hospital for treatment. Similarly, a high need was also identified for modifying the initially planned treatment in polyatherosclerotic patients. In these patients, any modification of treatment was always based on the location of the multilevel occlusive or aneurysmal arterial disease, and on its severity. Angioplasty, alone or in combination with stenting, was the treatment of choice whenever possible, which is in agreement with international literature [6, 10, 19, 30, 45, 47]. The results demonstrate that, in polyatherosclerotic patients, whenever there was a need to modify the initially planned therapy, endovascular surgery monopolized the field of treatment, because it is easily applied and does not affect the patient's status considerably. According to the results of the study, surgery provided better immediate and long-term patency and is the first line of treatment in occlusive and aneu-rysmal vascular disease. Finally, the use of intravascular ultrasonography (IVUS) before angioplasty may facilitate the selection of patients for endovascular treatment, especially in the polyvascular patients.

2.8.3 Multifocal Occlusive and Aneurysmal Arterial Disease

Combined occlusive coronary artery disease and aortic aneurysm may frequently exist in the same patient and represents a difficult vascular condition from the management point of view [14, 42-45]. In such patients, it is not easy to predict the necessity for coronary artery by-pass grafting (CABG) without conducting coronary angiography. Consequently, this can justify the routine enforcement of preoperative coronary catheterization in most cases of aortic aneurysm [18, 20, 21]. However, it has been demonstrated that in the presence of abdominal aortic aneurysm the incidence of patients requiring CABG first was small (about 4.5%). A similarly small percentage was reported in cases of thoracic aortic aneurysms [3, 38, 46]. According to this information, routine preoperative cardiac evaluation before aortic aneurysm repair may contribute little information with an impact on treatment, and therefore most patients with aortic aneurysm may undergo surgery safely with no cardiac workup [14]. In the case of staging of the corrective procedures, surgical repair of coronary artery disease in patients with coexisting large abdominal aortic aneurysms may increase the rate of aortic aneurysm rupture. This is why one-stage CABG and aortic aneurysm repair has been recommended by several surgeons as an alternative to staged intervention, but with a higher mortality rate [5, 20].

Data analysis of the study led to the following six options concerning escalation of the corrective procedure:

• Option 1. One-stage CABG and simultaneous aortic aneurysm repair carried out either during or after car-diopulmonary by-pass. Abdominal aortic aneurysm repair during cardiopulmonary by-pass is recommended in patients with established left ventricular dysfunction.

• Option 2. One-stage CABG performed with a beating heart and simultaneous abdominal aortic aneurysm repair.

• Option 3. Two-stage procedure consisting of CABG followed by aortic aneurysm repair at a later stage. Recommended timing for the repair of the abdominal aortic aneurysm is 2 months after myocardial revas-cularization.

• Option 4. Reversed two-stage procedure consisting of repairing the abdominal aortic aneurysm first and the CABG later.

• Option 5. Angioplasty and stenting for the coronary artery disease, performed as a first procedure to correct unstable angina, followed by the repair of the abdominal aortic aneurysm.

• Option 6. Endovascular repair of the abdominal aortic aneurysm performed as a first procedure, followed by CABG.

The above options are based on the experience of the team that conducted the study. In patients with unstable angina options 5 and 6 are recommended. In patients with severe coronary artery disease combined with large aortic aneurysm options 2 and 6 are preferred. In patients with stable angina and an asymptomatic, non-tender abdominal aortic aneurysm, option 3 is recommended. Option 1 is recommended in younger patients with a combination of severe coronary artery disease and a quickly expanding large abdominal aortic aneurysm, although in such patients a one-stage operation with off-pump CABG is also an attractive option (option 2). Option 1 is also recommended for the repair of combined aneurysm of the ascending aorta and CABG.

On reviewing the international literature, it may be noted that it is not possible to proceed with firm recommendations regarding the management strategy, mainly due to the lack of a large series of patients with critical coronary artery disease and aortic aneurysm. The following extra recommendations are debated on the basis of published literature:

• If the abdominal aortic aneurysm is not tender and has a diameter of 5.45-8 cm a combined approach may be a better option [14, 45].

• Performing CABG with a beating heart will help to avoid the risk of abdominal aortic aneurysm rupture during the interval between the two operations.

• Endoluminal repair of abdominal aortic aneurysm offers a further option, both for stage and reversed-stage approaches and may be applied in patients with large aneurysms amenable to this therapeutic modality.

• The same options exist for patients with coexistent coronary, aortic and severe peripheral disease (critical limb ischaemia) [22, 24, 25, 47]. In these patients endoluminal repair becomes even more attractive because it repairs some of the existing arterial problems of the polyvascular patient, with low mortality and morbidity.

• Also, there are reported cases of simultaneous carotid endarterectomy, CABG and repair of abdominal aortic aneurysm, as well as reports of one-stage operations in combined thoracoabdominal aortic aneurysm and coronary artery disease [5, 12, 23, 27, 29].

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