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Coronary Artery Disease in Patients with Aortoiliac Occlusive Disease and Abdominal Aortic Aneurysm
Diseases of the abdominal aorta and aortoiliac system share many important pathophysiologic factors with coronary artery disease (CAD). Many of the risk factors that contribute to abdominal aortic aneurysms (AAA) and aortoiliac occlusive disease (AIOD), including diabetes, tobacco use, hyperlipidemia, and advanced age, are also risk factors for CAD. Accordingly, a prudent surgeon must always keep CAD in mind when treating a patient who has diseases of the abdominal aorta and aortoiliac system. Despite decreasing morbidity and mortality rates for surgical treatment of abdominal aortic aneurysm and aortoiliac disease, CAD remains an important cause of perioperative morbidity and mortality. Patients with peripheral vascular disease who have significant CAD have been shown to have decreased long-term survival.
Importance of Coronary Artery Disease
A number of studies have reported on the incidence and outcomes of patients with comorbid CAD and AAA or AIOD. In 1989, Johnston and colleagues reported a cardiac event rate of approximately 15% among 666 patients who underwent operation for nonruptured AAAs, with the highest probability of postoperative myocardial infarction (MI) occurring in older patients with a history of angina. In 1994, Chen and colleagues reported that patients with nonruptured AAAs had a fivefold increase in mortality if they experienced a perioperative MI (odds ratio [OR], 5.0; p < .01), and patients with ruptured AAAs who survived the initial operative had a fourfold increase in mortality if they experienced a perioperative MI.
Similarly, in the Coronary Artery Revascularization Prophylaxis (CARP) trial, 5859 veterans undergoing elective surgery for AAA or AIOD at Veterans Administration Hospitals were assessed by for cardiac risk. The study’s 1190 patients judged to have increased cardiac risk underwent coronary arteriography. Nonobstructive coronary artery disease was evident in 363, and 510 had more significant CAD. The latter were randomized to coronary revascularization or medical management with no revascularization. Ninety-nine patients underwent CABG, and 141 underwent a percutaneous coronary intervention. With an average of 2.7 years of follow-up, there was no difference in outcome: 22% of the patients who underwent revascularization and 23% of the patients who underwent medical management with no revascularization died, p = .92.
Endovascular aneurysm repair (EVAR) has become more common. An EVAR trial conducted between 1999 and 2004 randomized 1252 patients to endovascular or open repair of AAA and followed patients for MI, stroke, or death until 2009. The investigators identified a total of 187 cardiovascular events (98 MIs and 89 strokes). The rates of cardiovascular events appeared to be lower in the EVAR group (2.6 vs. 3.2 events per 100 person-years), but this was not found to be statistically significant, p = .199.
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