Perioperative clinical variables and long-term survival following vascular surgery

Cardiovascular disease is the leading cause of death in patients with peripheral arterial disease(PAD). Coro-nary 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 re-vascularization in patients with stable CAD, with the sole intention to mitigate the risk of cardiac complica-tions in the peri-operative period, is not effective and may be associated with significant bleeding and throm-botic 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 cardiactroponin 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 as-sessing the role of novel anticoagulants. Additional research is needed to define the role of cardiac imaging and invasive angiography in this population.

Reintervention with Transcatheter and Surgical Aortic Valves: A Systematic Review and Meta-Analysis

Background: Despite expanding indications, data regarding the long-term durability of transcatheter heart valves (THV) are limited. Methods: We performed a systematic review and meta-analysis of all published studies with ≥5years of follow-up reporting aortic valve reintervention rates of transcatheter (TAVR) and surgical aortic valve replacement (SAVR). Randomized controlled trials (n = 4) and propensity-matched observational studies (n = 1) involving all surgical risk categories were included. The primary endpoint was the composite of aortic valve reintervention and death. Results: The meta- analysis included 4145 patients: 2101 underwent TAVR (mean age 81.7 ± 6.7 years, 54% male) and 2044 SAVR (mean age 81.8 ± 6.6 years, 54% male). All TAVR procedures were performed with early generations of THV. At a median follow-up of 5 years (range 5 - 6 years), TAVR had higher reintervention rates (odds ratio (OR) 3.33;95% CI: [1.78, 6.24], p < 0.001, I2 = 0%), all-cause mortality (OR 1.45;95% CI: [1.22, 1.75], p < 0.001, I2 = 44%) and the composite of reintervention and death (OR 1.47;95% CI: [1.14, 1.91], p < 0.001, I2 = 64%). Rates of myocardial infarction, transient ischemic attack, stroke, endocarditis, and the composite of endocarditis and thrombosis were similar between the groups. Conclusion: Despite comparable short and medium-term results, TAVR with early-generation THV has higher rates of reintervention and the composite of reintervention and death. Further studies employing newer definitions of structural valve deterioration and bioprosthetic valve failure are needed to assess whether technological enhancements in THV technology will improve long-term outcomes.

反对：高危患者在血管外科手术前应行冠状动脉重建术

临床麻醉医师常常面对高危非心脏手术患者手术前危险分级的困难。总的来说，实施择期手术、患一般内科疾病而无心脏症状的患者围手术期发生心脏并发症的风险极低；因此，可能不需要特殊的辅助检查。然而正如Kenai的综述中所讨论到的，接受血管外科手术的患者常患有动脉粥样硬化性心脏病，当涉及到主动脉和动脉手术操作时会出现复杂的血液动力学变化，手术前需要特别注意。冠状动脉疾病是所有血管外科手术术后死亡的主要原因，因此手术前考虑行冠状动脉重建术无可厚非。