Abstracts
BACKGROUND:
Atherosclerosis is the main cause of peripheral artery occlusive disease (PAOD) of the lower limbs. Patients with PAOD often also have obstructive atherosclerosis in other arterial sites, mainly the coronary arteries. This means that patients who undergo infrainguinal bypass to treat critical ischemia have a higher risk of AMI. There are, however, few reports in the literature that have assessed this risk properly.
OBJECTIVE:
The aim of this study was to determine the incidence of acute myocardial infarction in patients who underwent infrainguinal bypass to treat critical ischemia of the lower limbs caused by PAOD.
MATERIAL AND METHODS:
A total of 64 patients who underwent 82 infrainguinal bypass operations, from February 2011 to July 2012 were studied. All patients had electrocardiograms and troponin I blood assays during the postoperative period (within 72 hours).
RESULTS:
There were abnormal ECG findings and elevated blood troponin I levels suggestive of AMI in five (6%) of the 82 operations performed. All five had conventional surgery. The incidence of AMI as a proportion of the 52 conventional surgery cases was 9.6%. Two patients died.
CONCLUSION:
There was a 6% AMI incidence among patients who underwent infrainguinal bypass due to PAOD. Considering only cases operated using conventional surgery, the incidence of AMI was 9.6%.
peripheral arterial disease; myocardial infarction; postoperative period
CONTEXTO:
A doença arterial obstrutiva periférica (DAOP) afeta os membros inferiores (MMII) e tem como principal causa a aterosclerose. Por se tratar de uma doença sistêmica, é frequente que a aterosclerose cause o envolvimento simultâneo de outros sítios arteriais, especialmente das artérias coronárias. Desta forma, os pacientes submetidos a cirurgia de reconstrução arterial periférica, devido a isquemia crítica dos MMII, apresentam maior chance de infarto agudo do miocárdico (IAM). Apesar disso, há na literatura poucos relatos que avaliem a prevalência do IAM adequadamente neste grupo de pacientes.
OBJETIVO:
Avaliar incidência do infarto agudo do miocárdio no pós-operatório imediato de pacientes submetidos à revascularização de MMII devido a DAOP.
MATERIAL E MÉTODOS:
Foram avaliados 64 pacientes portadores de DAOP submetidos a 82 cirurgias de revascularização arterial dos MMII, no período de fevereiro de 2011 a julho de 2012. Os pacientes foram submetidos no pós-operatório imediato (até 72 horas) a eletrocardiograma (ECG) e dosagem sanguínea de troponina I cardíaca.
RESULTADOS:
Considerando as 82 cirurgias realizadas, em cinco (6%) casos, foram encontradas alterações no ECG e elevação sanguínea da troponina I cardíaca compatíveis com infarto agudo do miocárdio. Considerando apenas as 52 cirurgias feitas por técnica convencional, a incidência de IAM foi de 9,6%. Dois pacientes evoluíram ao óbito.
CONCLUSÃO:
No presente estudo, a incidência do infarto agudo do miocárdio nos pacientes submetidos à revascularização arterial de membros inferiores por DAOP foi de 6%. Considerando apenas as cirurgias feitas por técnica convencional, a incidência de IAM foi de 9,6%.
doença arterial periférica; infarto do miocárdio; período pós-operatório
INTRODUCTION
There is a high prevalence of Coronary Artery Disease (CAD) among patients with
Peripheral Arterial Occlusive Disease (PAOD) and in the majority of cases
atherosclerosis is the cause of both conditions. These patients are considered high risk
for surgery11. Norgren L, Hiatt WR, Dormandy JA, Nehler KAH, Fowkes FGR on behalf of
the TASC II working Group. Inter-Society Consensus for the management of peripheral
Arterial Disease (TASC II). J Vasc Bras. 2007;6(Supl 2):S193-259.
2. Iran castro, coordenador. II Diretriz de Avaliação Perioperatória da
Sociedade Brasileira de Cardiologia. Arq Bras Cardiol. 2011;96(3
supl.1):1-68.
3. Lastoria S, Maffei FHA. Aterosclerose Obliterante Periférica:
Epidemiologia, Fisiopatologia, Quadro Clínico e Diagnóstico. In: Maffei FHA, Lastoria
S, Yoshida WB, Rolol HA, Gianini M, Moura R. Doenças Vasculares Periféricas. 4. ed.
Rio de Janeiro: Guanabara-Koogan; 2008. p. 1141-55.
4. Mello AV, Dos Santos CMT, Oliveira BC, Mello RV. Revascularização
distal dos membros inferiores: experiência de 13 anos J Vasc Bras.
2002;1:181-92.
-
55. Mourad JJ, Cacoub P, Collet JP, et al. Screening of unrecognized
peripheral arterial disease (PAD) using ankle-brachial index in high cardiovascular
risk patients free from symptomatic PAD. J Vasc Surg. 2009;50:572-80. PMid:19560312.
http://dx.doi.org/10.1016/j.jvs.2009.04.055
http://dx.doi.org/10.1016/j.jvs.2009.04....
.
All PAOD patients should undergo detailed preoperative cardiac assessment with the
objective of identifying cases with concomitant myocardial ischemia. These assessments
are particularly important for patients with critical ischemia of the lower extremities
(MMII) and for candidates for lower extremity revascularization surgery, because
surgical stress, involving elevated catecholamine production, leading to tachycardia,
vasoconstriction and myocardial hypoxia, increases their risk of acute myocardial
infarction (AMI)66. Kim LJ, Martinez EA, Faraday N, et al. Cardiac troponin-I predicts
short-term mortality in vascular surgery patients. Circulation. 2002;106:2366-71.
PMid:12403668. http://dx.doi.org/10.1161/01.CIR.0000036016.52396.BB
http://dx.doi.org/10.1161/01.CIR.0000036...
7. Kertai JH, Boersma E, Bax JJ, et al. A meta-analysis comparing the
prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk
in patients undergoing major vascular surgery. Heart. 2003 Nov;89(11):1327-34.
PMid:14594892 PMCid:PMC1767930.
http://dx.doi.org/10.1136/heart.89.11.1327
http://dx.doi.org/10.1136/heart.89.11.13...
8. Scrutinio D, Passantino A, Di Serio F, Angilleta D, Santoro D, Regina
G. High-sensitivity C-reactive protein predicts cardiovascular events and myocardial
damage after vascular surgery. J Vasc Surg. 2011;54:474-9. PMid:21458205.
http://dx.doi.org/10.1016/j.jvs.2011.01.041
http://dx.doi.org/10.1016/j.jvs.2011.01....
9. Frankini AD, Pezzella MVC. Revascularização no pé em paciente com
isquemia crítica. J Vasc Br. 2002;1(3):193-200.
10. Boersma E, Kertai MD, Schouten O, et al. Perioperative
cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk
index. Am J Med. 2005; 118(10):1134-41. PMid:16194645.
http://dx.doi.org/10.1016/j.amjmed.2005.01.064
http://dx.doi.org/10.1016/j.amjmed.2005....
-
1111. Landesberg G, Mosseri M, Shatz V, et al. Cardiac Troponin After
Major Vascular Surgery. JACC. 2004;44:569-75. PMid:15358022.
http://dx.doi.org/10.1016/j.jacc.2004.03.073
http://dx.doi.org/10.1016/j.jacc.2004.03...
during the perioperative period.
Acute myocardial infarction is the principal cardiac complication and greatest cause of
death during the perioperative period of lower extremity revascularization surgery, i.e.
from 30 days before to 30 days after surgery, although the most common time of onset is
within the first 72 postoperative hours1212. Raby KE, Barry J, Creager MA, Cook EF, Weisberg MC, Goldman L.
Detection and significance of intraoperative and postoperative myocardial ischemia in
peripheral vascular surgery. JAMA. 1992;268(2):222-7. PMid:1608141.
http://dx.doi.org/10.1001/jama.1992.03490020070033
http://dx.doi.org/10.1001/jama.1992.0349...
13. Bolliger D, Seeberger MD, Lurati Buse GA, et al. A preliminary
report on the prognostic significance of preoperative brain natriuretic peptide and
postoperative cardiac troponin in patients undergoing major vascular surgery. Anesth
Analg. 2009;108(4):1069-75. PMid:19299763.
http://dx.doi.org/10.1213/ane.0b013e318194f3e6
http://dx.doi.org/10.1213/ane.0b013e3181...
14. Back MR, Leo F, Cuthbertson D, Johnson BL, Shamesmd ML, Bandyk DF.
Long-term survival after vascular surgery: specific influence of cardiac factors and
implications for preoperative evaluation. J Vasc Surg. 2004 Oct;40(4):752-60.
PMid:15472605. http://dx.doi.org/10.1016/j.jvs.2004.07.038
http://dx.doi.org/10.1016/j.jvs.2004.07....
15. Williams FM, Bergin JD. Cardiac screening before noncardiac surgery.
Surg Clin North Am. 2009 Aug;89(4):747-62. PMid:19782835.
http://dx.doi.org/10.1016/j.suc.2009.05.001
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1616. Waggoner AD, Sicard GA, Geltman EM, Schechtman KB, Pérez JE.
Dobutamine stress echocardiography predicts surgical outcome in patients with an
aortic aneurysm and peripheral vascular disease. J Am Coll Cardiol. 1993 Mar
15;21(4):957-63. http://dx.doi.org/10.1016/0735-1097(93)90353-3
http://dx.doi.org/10.1016/0735-1097(93)9...
.
While the link between PAOD and CAD has been definitively demonstrated in the
literature, few studies have clearly established the incidence of postoperative AMI
among infrainguinal revascularization patients. In view of these considerations, the
objective of this study was to evaluate the incidence of AMI among patients with
critical ischemia who had undergone revascularization of the lower extremities1515. Williams FM, Bergin JD. Cardiac screening before noncardiac surgery.
Surg Clin North Am. 2009 Aug;89(4):747-62. PMid:19782835.
http://dx.doi.org/10.1016/j.suc.2009.05.001
http://dx.doi.org/10.1016/j.suc.2009.05....
16. Waggoner AD, Sicard GA, Geltman EM, Schechtman KB, Pérez JE.
Dobutamine stress echocardiography predicts surgical outcome in patients with an
aortic aneurysm and peripheral vascular disease. J Am Coll Cardiol. 1993 Mar
15;21(4):957-63. http://dx.doi.org/10.1016/0735-1097(93)90353-3
http://dx.doi.org/10.1016/0735-1097(93)9...
17. Poldermans D, Bax JJ, Boersma E, et al. Guidelines for pre-operative
cardiac risk assessment and perioperative cardiac management in non-cardiac surgery.
Eur Heart J. 2009;30:2769-812. PMid:19713421.
http://dx.doi.org/10.1093/eurheartj/ehp337
http://dx.doi.org/10.1093/eurheartj/ehp3...
18. Thygesen K, Alpert SJ, Jaffe SA, et al. Third Universal Definition
of Myocardial Infarction. JACC. 2012;60.
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1919. Monaco M, Stassano P, Di Tommaso L, et al. Systematic strategy of
prophylactic coronary angiography improves long-term outcome after major vascular
surgery in medium- to high-risk patients: a prospective, randomized study. J Am Coll
Cardiol. 2009 Sep 8;54(11):989-96. PMid:19729114.
http://dx.doi.org/10.1016/j.jacc.2009.05.041
http://dx.doi.org/10.1016/j.jacc.2009.05...
.
MATERIALS AND METHODS
A total of 64 patients who had undergone 82 infrainguinal revascularization procedures, whether by conventional open or endovascular techniques, were studied. All of the patients had critical ischemia of the lower extremities, 33 were male and 31 were female. The patients were recruited from the vascular surgery ward at the Instituto de Medicina Integral Prof. Fernando Figueira between February 2011 and November 2012.
Forty-three of the patients had just one procedure, while 18 underwent two revascularization operations. Patients who were revascularized twice were admitted on a separate occasion for the second procedure and had another preoperative cardiac assessment before it.
The study design is of the observational cross-sectional type (a case series). Sample size was calculated using hypothesis testing for a population proportion (assuming that 15% of arterial revascularization surgery patients will suffer AMI, based on published data, a hypothesized proportion of 6%, test power of 85% and a 5% significance level). The study was approved with no restrictions by the Human Research Ethics Committee.
All patients were assessed for AMI during the immediate postoperative period (within 72 hours). Acute myocardial infarction was diagnosed by assaying cardiac troponin I in blood, by analyzing electrocardiograms (ECG) and by observing signs and symptoms of myocardial ischemia. Cardiac troponin I was tested by immunoassay and 12-lead ECG was used.
Patients were diagnosed with AMI if their blood troponin I was greater than or equal to 1.5 ng/mL in combination with precordial pain (and/or hypotension) or with an ECG showing ST segment elevation on at least two consecutive leads, as recommended by the second edition of the Sociedade Brasileira de Cardiologia's perioperative assessment guidelines.
Preoperative cardiac assessment was conducted for all elective procedures. In addition to clinical examination, patients had a simple chest X-ray, ECG, echocardiogram and resting and stressed myocardial perfusion scintigraphy. Patients whose scintigraphy results suggested myocardial ischemia were referred for coronary cineangiography to assess whether myocardial revascularization was needed prior to revascularization of the lower limb. For elective surgery patients, antiplatelet treatment with acetylsalicylic acid at 100 mg / day was started 15 days before surgery and continued during the postoperative period, while patients who had emergency surgery and were not already on the drug were only prescribed it after surgery.
RESULTS
A total of 64 patients were studied, with a minimum age of 31 and a maximum age of 98 (mean of 64.3 years).
Clinical manifestations of PAOD were as follows: 61 (95.3%) patients had minor tissue loss (Rutherford stage 4), while 3 (4.7%) had rest pain (Rutherford stage 3).
Risk factors detected were as follows: 57 (89%) patients had systemic arterial hypertension (HAS); 42 (73.4%) were diabetic; 32 (50%) had a history of smoking; and 11 (17.2%) had chronic renal failure (IRC), Figure 1.
Fifty-nine patients underwent preoperative cardiac assessment for a total of 77 (94%) procedures, while 5 (6%) patients were admitted for emergency surgery, meaning preoperative cardiac assessment was not possible. After the initial preoperative assessment, 11 (17%) patients were referred for coronary cineangiography and 4 (6%) were then subjected to revascularization of the myocardium before proceeding to infrainguinal revascularization.
Fifty-two (63.4%) of the 82 infrainguinal revascularizations were conducted using conventional open surgery and 30 (36.6%) were conducted using endovascular techniques (Figure 2).
There were 5 (6%) cases of AMI during the postoperative periods of the 82 inguinal revascularization operations performed. Four (80%) of the 5 patients who suffered AMI had had preoperative cardiac assessments, whereas 1 (20%) of them was operated as an emergency case and so did not. None of the AMI cases were in patients who had undergone coronary cineangiography and myocardial revascularization prior to infrainguinal revascularization.
The mean age of patients who suffered AMI during the postoperative period was 63.6 years and median age was 68. Table 1 lists the characteristics of patients who suffered AMI during the postoperative period.
All of the AMI cases were in patients whose revascularization was performed using conventional surgical techniques. Indeed, if endovascular operations are excluded, the rate of AMI in the subset of open surgery patients is 9.6%.
All of the AMI patients had high Troponin I levels and abnormal ECG findings (elevated ST segment) and 2 of them also exhibited hypotension.
DISCUSSION
Several different studies have established that there is a relationship between cardiac
complications and a range of different types of arterial reconstruction surgery, but the
association between AMI and infrainguinal revascularization surgery in patients with
critical ischemia of lower extremities has rarely been described as in the present
study. In contrast, the risk of AMI related to aortic surgery to treat aneurysms, for
example, has been described at length2020. Andrews N, Jenkins J, Andrews G, Walker P. Using postoperative
cardiac Troponin-I (cTi) levels to detect myocardial ischaemia in patients undergoing
vascular surgery. Cardiovasc Surg. 2001;9(3):254-65.
http://dx.doi.org/10.1016/S0967-2109(00)00139-3
http://dx.doi.org/10.1016/S0967-2109(00)...
21. Haggart PC, Adam DJ, Ludman PF, Bradbury AW. Comparison of cardiac
troponin I and creatine kinase ratios in the detection of myocardial injury after
aortic surgery. Br J Surg. 2001;88(9):1196-200. PMid:11531867.
http://dx.doi.org/10.1046/j.0007-1323.2001.01854.x
http://dx.doi.org/10.1046/j.0007-1323.20...
22. Barbagallo M, Casati A, Spadini E, et al. Early increases in cardiac
troponin levels after major vascular surgery is associated with an increased
frequency of delayed cardiac complications. J Clin Anesth. 2006;18(4):280-5.
PMid:16797430. http://dx.doi.org/10.1016/j.jclinane.2005.11.005
http://dx.doi.org/10.1016/j.jclinane.200...
23. McFalls EO, Ward HB, Moritz TE, et al. Predictors and outcomes of a
perioperative myocardial infarc- tion following elective vascular surgery in patients
with docu- mented coronary artery disease: results of the CARP trial. Eur Heart J.
2008; 29(3):394-401. PMid:18245121.
http://dx.doi.org/10.1093/eurheartj/ehm620
http://dx.doi.org/10.1093/eurheartj/ehm6...
24. Flu JW, Schouten O, Van Kuijk PJ, Poldermans D. Perioperative
Cardiac Damage in Vascular Surgery Patients. Eur J Vasc Endovasc Surg. 2010;40:1-8.
PMid:20400340. http://dx.doi.org/10.1016/j.ejvs.2010.03.014
http://dx.doi.org/10.1016/j.ejvs.2010.03...
25. Landesberg G, Mosseri M, Zahger D, et al. Myocardial Infarction
After Vascular Surgery: The Role of Prolonged, Stress-Induced, ST Depression-Type
Ischemia. JACC. 2001;37:1839-45.
http://dx.doi.org/10.1016/S0735-1097(01)01265-7
http://dx.doi.org/10.1016/S0735-1097(01)...
-
2626. Landesberg G, Shatz V, Akopnik I, et al. Association of Cardiac
Troponin, CK-MB, and Postoperative Myocardial Ischemia With Long-Term Survival After
Major Vascular Surgery. JACC. 2003;42:1547-54. PMid:14607436.
http://dx.doi.org/10.1016/j.jacc.2003.05.001
http://dx.doi.org/10.1016/j.jacc.2003.05...
.
The risk of AMI linked to other types of arterial reconstruction, other than aortic
surgery, was described by Flu et al.2424. Flu JW, Schouten O, Van Kuijk PJ, Poldermans D. Perioperative
Cardiac Damage in Vascular Surgery Patients. Eur J Vasc Endovasc Surg. 2010;40:1-8.
PMid:20400340. http://dx.doi.org/10.1016/j.ejvs.2010.03.014
http://dx.doi.org/10.1016/j.ejvs.2010.03...
in a 2010 review of 13 articles published from 2000 to 2009 assessing AMI risk
in connection with several different types of arterial reconstruction, including surgery
to the aorta and carotid arteries and also infrainguinal revascularizations of lower
extremities, as studied here. The overall incidence of AMI varied from 1 to 26 %, but
there was no data on the risk of AMI related specifically to infrainguinal
revascularizations.
Similarly, in 2001 Landesberg et al.2525. Landesberg G, Mosseri M, Zahger D, et al. Myocardial Infarction
After Vascular Surgery: The Role of Prolonged, Stress-Induced, ST Depression-Type
Ischemia. JACC. 2001;37:1839-45.
http://dx.doi.org/10.1016/S0735-1097(01)01265-7
http://dx.doi.org/10.1016/S0735-1097(01)...
reported AMI incidence in 185 patients after a range of different arterial
reconstruction procedures, including 73 cases of infrainguinal revascularization. In
that study, 12 (6.5%) patients had postoperative AMI, but no AMI incidence was reported
for the specific subset of patients who underwent infrainguinal revascularization.
In 2003, Landesberg et al.2626. Landesberg G, Shatz V, Akopnik I, et al. Association of Cardiac
Troponin, CK-MB, and Postoperative Myocardial Ischemia With Long-Term Survival After
Major Vascular Surgery. JACC. 2003;42:1547-54. PMid:14607436.
http://dx.doi.org/10.1016/j.jacc.2003.05.001
http://dx.doi.org/10.1016/j.jacc.2003.05...
conducted a prospective study of 447 patients who underwent revascularization of
varying arterial sites, such as the aorta and the carotid and infrainguinal arteries,
reporting that 23.9% of the patients had postoperative AMI, but this study also failed
to report an AMI rate specific to infrainguinal revascularization patients.
The lower AMI incidence (6%) observed in this study, compared with reports in the
literature, may be explainable by the fact that the majority of studies included
patients who had had surgery for reconstruction of the aorta, since these cases involve
greater hemodynamic stress, caused by factors such as clamping the aorta, greater blood
loss and longer duration anesthesia, which increases the risk of AMI. Additionally,
patients whose revascularization was conducted using endovascular techniques did not
suffer AMI, which may be because these methods reduce hemodynamic stress further
still2020. Andrews N, Jenkins J, Andrews G, Walker P. Using postoperative
cardiac Troponin-I (cTi) levels to detect myocardial ischaemia in patients undergoing
vascular surgery. Cardiovasc Surg. 2001;9(3):254-65.
http://dx.doi.org/10.1016/S0967-2109(00)00139-3
http://dx.doi.org/10.1016/S0967-2109(00)...
21. Haggart PC, Adam DJ, Ludman PF, Bradbury AW. Comparison of cardiac
troponin I and creatine kinase ratios in the detection of myocardial injury after
aortic surgery. Br J Surg. 2001;88(9):1196-200. PMid:11531867.
http://dx.doi.org/10.1046/j.0007-1323.2001.01854.x
http://dx.doi.org/10.1046/j.0007-1323.20...
22. Barbagallo M, Casati A, Spadini E, et al. Early increases in cardiac
troponin levels after major vascular surgery is associated with an increased
frequency of delayed cardiac complications. J Clin Anesth. 2006;18(4):280-5.
PMid:16797430. http://dx.doi.org/10.1016/j.jclinane.2005.11.005
http://dx.doi.org/10.1016/j.jclinane.200...
23. McFalls EO, Ward HB, Moritz TE, et al. Predictors and outcomes of a
perioperative myocardial infarc- tion following elective vascular surgery in patients
with docu- mented coronary artery disease: results of the CARP trial. Eur Heart J.
2008; 29(3):394-401. PMid:18245121.
http://dx.doi.org/10.1093/eurheartj/ehm620
http://dx.doi.org/10.1093/eurheartj/ehm6...
24. Flu JW, Schouten O, Van Kuijk PJ, Poldermans D. Perioperative
Cardiac Damage in Vascular Surgery Patients. Eur J Vasc Endovasc Surg. 2010;40:1-8.
PMid:20400340. http://dx.doi.org/10.1016/j.ejvs.2010.03.014
http://dx.doi.org/10.1016/j.ejvs.2010.03...
25. Landesberg G, Mosseri M, Zahger D, et al. Myocardial Infarction
After Vascular Surgery: The Role of Prolonged, Stress-Induced, ST Depression-Type
Ischemia. JACC. 2001;37:1839-45.
http://dx.doi.org/10.1016/S0735-1097(01)01265-7
http://dx.doi.org/10.1016/S0735-1097(01)...
-
2626. Landesberg G, Shatz V, Akopnik I, et al. Association of Cardiac
Troponin, CK-MB, and Postoperative Myocardial Ischemia With Long-Term Survival After
Major Vascular Surgery. JACC. 2003;42:1547-54. PMid:14607436.
http://dx.doi.org/10.1016/j.jacc.2003.05.001
http://dx.doi.org/10.1016/j.jacc.2003.05...
.
Additionally, the patients in this study were put on anti-platelet drugs from the
preoperative period onwards, which has been described as a protective factor against
AMI. The role of acetylsalicylic acid in preventing death, acute myocardial infarction
and cerebral vascular accidents in patients at high risk of occlusive cardiovascular
events was fully demonstrated by the Antithrombotic Trialists Collaboration (ATC) in
2002, when 287 studies involving 135,000 patients comparing antiplatelet treatment with
placebo were analyzed11. Norgren L, Hiatt WR, Dormandy JA, Nehler KAH, Fowkes FGR on behalf of
the TASC II working Group. Inter-Society Consensus for the management of peripheral
Arterial Disease (TASC II). J Vasc Bras. 2007;6(Supl 2):S193-259.
,
2727. ATC. Collaborative meta-analysis of randomized trials of
antiplatelet therapy for prevention of death, myocardial infarction, and stroke in
high risk patients. BMJ. 2002;324:71-86.
http://dx.doi.org/10.1136/bmj.324.7329.71
http://dx.doi.org/10.1136/bmj.324.7329.7...
.
The low AIM incidence observed in this study may also owe something to the rigorous preoperative cardiac assessment that made it possible to identify patients in need of coronary revascularization prior to revascularization of the lower extremities, even though this assessment could not be performed in five cases because surgery was in response to an emergency.
The indications for coronary revascularization used here are based on the recommendations contained in the second edition of the Sociedade Brasileira de Cardiologia's perioperative assessment guidelines which demand myocardial scintigraphy when ergometric tests are ruled out by physical limitations, which is the case with the majority of patients with critical ischemia of the lower extremities. In this study, patients were sent for coronary cineangiography if they had scintigraphy findings indicating ischemia22. Iran castro, coordenador. II Diretriz de Avaliação Perioperatória da Sociedade Brasileira de Cardiologia. Arq Bras Cardiol. 2011;96(3 supl.1):1-68..
CONCLUSIONS
The incidence of acute myocardial infarction among patients who underwent arterial revascularization of the lower extremities because of Peripheral Arterial Occlusive Disease was 6%, but if patients whose revascularization was conducted using conventional surgery are analyzed separately, the incidence of AMI rises to 9.6%.
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*All authors have read and approved of the final version of the article submitted to J Vasc Bras.
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Study carried out at the Vascular Surgery Service of Instituto de Medicina Integral Professor Fernando Figueira (IMIP).
Publication Dates
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Publication in this collection
Oct-Dec 2013
History
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Received
06 May 2013 -
Accepted
20 Aug 2013