Global Management of Concomitant Peripheral Vascular and Coronary Artery Diseases: The Role of the Invasive Cardiologist
- Fri, 9/5/08 - 3:36pm
- 0 Comments
- 3306 reads
INTRODUCTION
An early and accurate diagnosis of peripheral atherosclerosis (renal, abdominal and aortoiliac localizations) is of paramount importance for global management and prognosis due to its major additional mortality impact in patients with known coronary artery disease1-2, especially those who are candidates to coronary or cardiac revascularization (CAD).3-4 We sought to retrospectively evaluate the role of the invasive cardiologist in the diagnosis and management of clinically relevant significant subclavian artery stenosis (SAS) and abdominal vessel stenosis or aneurysm (AVA) diagnosed by coincident peripheral angiography in patients undergoing coronary angiography in whom CAD is detected.
MATERIALS AND METHODS
Medical records of consecutive patients who underwent coronary angiography at two 700-bed public institutions over a 12-month period were reviewed. On the basis of clear clinical and angiographic criteria (Table 1), patients underwent coincident diagnostic subclavian artery angiography in order to assess subclavian and internal mammary artery (IMA) in patient candidates for coronary surgery, using IMA or abdominal aorta angiography to evaluate renal, abdominal and iliac vessels. These patients were enrolled in a retrospective registry and analyzed. Written, informed consent was obtained from all patients. Pretreatment with 0.45% saline at a rate of 1ml/kg/hr for 12 h was administered to all patients. Repeated serum creatinine was obtained during admission and every two weeks until return to baseline values in patients exhibiting a procedure-related kidney dysfunction (increase in serum creatinine of > 0.5 mg/dl).
For subclavian artery angiography with visualization of LIMA, peripheral angiographic protocol included the use of a diagnostic modified or standard 5F Judkins right diagnostic catheter through the femoral or brachial artery, positioned at the origin of subclavian artery in anterior-posterior view and using the powered injection of > 4-8 ml of Iopromide (Ultravist 370, Schering, Milan, Italy). For abdominal angiography, a pigtail catheter was positioned at the level of the L1 vertebral body in the anterior-posterior to depict the abdominal aorta slightly above the renal arteries, to the origin of femoral arteries, using the powered injection of >30 ml of Iopromide (Ultravist 370, Schering, Milan, Italy). Alternatively, a Judkins Right coronary catheter has been used for selective renal artery angiography in the 20-25° left or right oblique projections using 4-8 ml. Digital subtractive technique was preferentially used. Moderate to severe vascular arterial stenosis (>50% stenosis), vessel occlusion, and aneurysmal vessels were noted as significant angiographic findings. Contrast-induced nephropathy was defined as a rise in serum creatinine of >25% from baseline.
STATISTICAL ANALYSIS
Data are expressed as mean ± SD and as percentages. Univariate and multivariate logistic regression analyses were employed to determine independent predictors of extra-cardiac atherosclerotic involvement. A significant level was defined when p< 0.05. All analyses were performed using SPSS 10.0 (SPSS Inc., Chicago, IL).
RESULTS
During the study period, 724 consecutive patients (535 males, mean age 68.1± 11 years) were enrolled (Table 2). A significant atherosclerotic disease at least one arterial segment was observed in 198 patients (27.3%). Angiographically-significant SAS was observed in 18 of 220 patients (8.1%) who underwent concomitant subclavian artery angiography and were candidates for coronary surgery using the internal mammary artery. Ten patients (55.5%) with subclavian artery stenosis and upper limb ischemia underwent subclavian artery angioplasty and stenting, and bypass surgery using LIMA. Angiographically significant AVA was observed in 180 of 504 (35.7%) patients undergoing concomitant abdominal aorta angiography. Renal artery stenosis was found in 13.1% of cases (66 patients), aortoiliac artery disease in 13.7% (69 patients), and aortic aneurismal disease in 8.9% (45 patients) including patients with combined renal artery and aortic stenosis, renal artery stenosis and abdominal aneurysm, and iliac stenosis/occlusion and thoracoabdominal aneurysmal disease. Significant AVA was associated with CAD in 98.8% (Table 3). Complications of combined coronary and subclavian or abdominal vessel angiography included 6 contrast-induced nephropathy. No case required renal replacement therapy. The additional contrast volume used for subclavian artery angiography was 8±2.6 ml, while for abdominal aorta and/or renal angiography, it was 38±15 ml. Cumulative additional fluoroscopy time was 5.0±1.1 minutes.
Ten patients (55.5%) with subclavian artery stenosis and upper limb ischemia underwent subclavian artery angioplasty and stenting, and bypass surgery using LIMA. In patient candidates for coronary surgery (89/180, 49.4%), abdominal angiography was useful in determining the need for prior percutaneous peripheral interventions in 48 patients, concomitant or staged vascular surgery in 41 patients, and unsuitability for any post-cardiac surgery aortic balloon counterpulsation in 14 patients. Globally, on the basis of standard clinical indications, an endovascular treatment was necessary in 40% (72 patients) and surgical vascular repair in 22.2% (40 patients) of cases. The remaining patients were medically managed for peripheral vascular disease and are currently being followed. Multivariate logistic regression analyses revealed:
• >3-vessel CAD (odds ratio[OR] 9.917; 95% confidence interval [CI] 2.2 to 43.8; p=0.002);
• Age >60 years (OR 3.817; 95% CI 2.2 to 6.5.8; p=0.036);
• and >3 risk factors (OR 2.8; CI 95% 0.63–9.1; p=0.048) as independent predictors of SAS and/or AVA (Table 4).
1. White CJ, Ramee SR, Collins TJ et al. Global revascularization: the role of the cardiologist. Int J Cardiovasc Intervent 2000; 3:71–79.
2. Rigatelli G, Zanchetta M. Interventional treatment of extra-cardiac atherosclerotic pathologies: an update about what the cardiologists should know. Ital Heart J 2004;5:99-113.
3. Iacovino JR. Additional mortality produced by co-existent cerebral and peripheral atherosclerosis in a population with coronary artery disease. J Insur Med 1998:30;68-75.
4. Eagle KA, Rihal CS, Foster ED et al. Long-term survival in patients with coronary artery disease: importance of peripheral vascular disease. The Coronary Artery Surgery Study (CASS) Investigators. J Am Coll Cardiol 1994;23:1091-1095.
5. English J, Carell E, Guidera S et al. Angiographic prevalence and clinical predictors of left subclavian stenosis in patients undergoing diagnostic cardiac catheterization. Catheter Cardiovasc Interv 2001;54:8-11.
6. Singh RN. Atherosclerosis and internal mammary arteries. Cardiovasc Intervent Radiol 1983;6:72-77.
7. Feit A, Reddy CV, Cowley C et al. Internal mammary artery angiography should be a routine component of diagnostic coronary angiography. Cathet Cardiovasc Diagn 1992;25:85-90.
8. Sons HJ, Godehardt E, Kunert J et al. Internal thoracic artery: prevalence of atherosclerotic changes. J Thorac Cardiovasc Surg 1993;106:1192-1195.
9. Finci L, Meier B, Steffenino G, et al. Nonselective preoperative digital subtraction angiography of internal mammary arteries. Cathet Cardiovasc Diagn 1990;19:13-16.
10. Chen CW, Lin TK, Chen BC et al. Preoperative semi-selective left internal mammary artery angiography: easy, safe, necessary and worthy. J Cardiovasc Surg (Torino). 2004;45:107-110.
11. Rigatelli G, Rigatelli G. Routine screening angiography of extra-cardiac arteries during cardiac catheterization: angiographer's delirium or common sense? Am J Med 2004;117:443-444.
12. Conlon PJ, Athirakul K, Kovalik E et al. Survival in renal vascular disease. J Am Soc Nephrol 1998;9:252-256.
13. Crowley JJ, Santos RM, Peter RH et al. Progression of renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J 1998;136:913-918.
14. Harding MB, Smith LR, Himmelstein SI et al. Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization. J Am Soc Nephrol 1992;2:1608-1616.
15. Gross CM, Kramer J, Waigand J et al. Renovascular illness: prevalence and therapy in patients with coronary heart disease. Z Kardiol 2000;89:747-753.
16. Valentine RJ, Clagett GP, Miller GL et al. The coronary risk of unsuspected renal artery stenosis. J Vasc Surg 1993;18:433-439.
17. Song HY, Hwang JH, Noh H et al. The prevalence and associated risk factors of renal artery stenosis in patients undergoing cardiac catheterization. Yonsei Med J 2000;41:219-225.
18. Conlon PJ, Little MA, Pieper K et al. Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography. Kidney Int 2001;60:1490-1497.
19. Shen Z, Shang Y, Zhu W. The prevalence of renal artery stenosis in patients with coronary artery disease. Zhonghua Nei Ke Za Zhi 2001 Aug;40(8):521-524.
20. Rihal CS, Textor SC, Breen JF et al. Incidental renal artery stenosis among a prospective cohort of hypertensive patients undergoing coronary angiography. Mayo Clin Proc 2002;77:309-316.
21. Yamashita T, Ito F, Iwakiri N et al. Prevalence and predictors of renal artery stenosis in patients undergoing cardiac catheterization. Hypertens Res 2002;25:553-557.
22. Rath PC, Agarwala MK, Dhar PK et al. Renal artery involvement in patients of coronary artery disease undergoing coronary angiography - a prospective study. J Assoc Physicians India 2002;50:523-526.
23. Khosla S, Kunjummen B, Manda R et al. Prevalence of renal artery stenosis requiring revascularization in patients initially referred for coronary angiography. Catheter Cardiovasc Interv 2003;58:400-403.
24. Buller CE, Nogareda JG, Ramanathan K et al. The profile of cardiac patients with renal artery stenosis. J Am Coll Cardiol. 2004;43:1606-1613.
25. Leandri M, Lipiecki J, Lipiecka E et al. Prevalence of renal artery stenosis in patients undergoing cardiac catheterization: when should abdominal aortography be performed? Results in 467 patients. J Radiol 2004;85:627-633.
26. Rigatelli G. Aortoiliac Angiography During Coronary Artery Angiography Detects Significant Occult Aortoiliac and Renal Artery Atherosclerosis in Patients with Coronary Atherosclerosis. Inter J Cardiovasc Imag 2004;20:299-303.
27. Thomas CS, Varghese K, Habib F et al. Extent and severity of atherosclerotic vascular disease in patients undergoing coronary angiography - the Kuwait Vascular Study. Angiology. 2003;54:85-92.
28. Suggs WD, Smith RB 3rd, Weintraub WS et al. Selective screening for coronary artery disease in patients undergoing elective repair of abdominal aortic aneurysms. J Vasc Surg 1993;18:349-355.
29. Kishi K, Ito S, Hiasa Y. Risk factors and incidence of coronary artery lesions in patients with abdominal aortic aneurysms. Intern Med 1997;36:384-388.
30. Zeldis SM, Wilkens JM, Goodman M et al. Unsuspected vascular disease: a potential limitation to the use of the intra-aortic balloon. Cathet Cardiovasc Diagn 1983;9:137-141.
31. Brooks MJ, Mayet J, Glenville Bl. Cardiac investigation and intervention prior to thoraco-abdominal aneurysm repair: coronary angiography in 35 patients. Eur J Vasc Endovasc Surg 2001;21:437-444.
32. Kieffer E, Chiche L, Baron JF et al. Coronary and carotid artery disease in patients with degenerative aneurysm of the descending thoracic or thoracoabdominal aorta: prevalence and impact on operative mortality. Ann Vasc Surg 2002;16:679-684.
33. El-Sabrout RA, Reul GJ, Cooley DA. Outcome after simultaneous abdominal aortic aneurysm repair and aortocoronary bypass. Ann Vasc Surg 2002;16:321-330.
34. Takahashi J, Okude J, Gohda T et al. Coronary artery bypass surgery in patients with abdominal aortic aneurysm: detection and treatment of concomitant coronary artery disease. Ann Thorac Cardiovasc Surg 2002;8:213-219.
35. Sasaki Y, Isobe F, Kinugasa S et al. Influence of coronary artery disease on operative mortality and long-term survival after abdominal aortic aneurysm repair. Surg Today 2004;34:313-317.
36. Rangel A, Albarran H, Solorio S et al. Angiographic concurrence of coronary artery disease and aortoiliac lesions. Angiology 2002;53:685-692.
37. Kafetzakis A, Giannoukas AD, Kochiadakis G et al. Occult aorto-iliac disease in patients with symptomatic coronary artery disease. Int Angiol 2001;20:295-300.
Post new comment