III. MANAGEMENT OF THE “POLYVASCULAR PATIENT”
2. ABDOMINAL AORTIC ANEURYSMS AND CONCOMITANT CORONARY DISEASE
A. Open repair  THE MULTIFOCAL ATHEROSCLEROTIC PATIENT
DIAGNOSIS AND MANAGEMENT IN 2003 

The Journal of Cardiovascular Surgery 2003 June;44(3):417-22

Copyright © 2009 EDIZIONI MINERVA MEDICA

lingua: Inglese

Progress in the treatment of aneurysms of the distal aortic arch: approach through median sternotomy

Galland R. B.

Department of Surgery Royal Berkshire Hospital Reading, UK

There is a ­high prev­a­lence of cor­o­nary ­artery dis­ease in ­patients ­with periph­er­al vas­cu­lar dis­ease (­PVD). Following elec­tive abdom­i­nal aor­tic aneu­rysm (­AAA) ­repair ­the com­mon­est ­cause ­for ­perioper­a­tive ­death is car­diac-relat­ed. Patients at ­high ­risk of devel­op­ing ­perioper­a­tive ­adverse car­diac ­events ­can be iden­ti­fied. Means of iden­tifi­ca­tion ­include clin­i­cal his­to­ry ­and exam­ina­tion ­with or with­out ­the cal­cu­la­tion of a scor­ing ­index, ­stress test­ing ­and meas­ure­ment of ejec­tion frac­tions. The ­use of dip­y­rid­a­mole thal­li­um scan­ning (­DTS) in ­patients ­with ­PVD ­results in ­about 1/3 of ­patients hav­ing nor­mal ­scans, 1/3 show­ing rever­sible ­and 1/3 ­fixed ­defects. It ­has ­been gen­er­al­ly accept­ed ­that ­fixed ­defects rep­re­sent a com­plet­ed myo­car­dial infarc­tion ­and ­patients ­are at no great­er ­risk of devel­op­ing ­perioper­a­tive car­diac com­pli­ca­tions ­than ­those ­patients ­with nor­mal ­scans. However, ­delayed ­scans ­show ­that ­some of ­these “­fixed” ­defects ­are in ­fact rever­sible. Evidence of a redis­tri­bu­tion ­defect ­implies myo­car­dial ischae­mia. The ­debate cen­tres on wheth­er iden­tifi­ca­tion of ­such ­defects ­and ­their cor­rec­tion ­will ­improve ­perioper­a­tive mor­tal­ity fol­low­ing ­AAA ­repair. There is no evi­dence ­that iden­tifi­ca­tion ­and cor­rect­ing cor­o­nary ­artery dis­ease in asymp­to­mat­ic ­patients ­ ­results either in ­improved oper­a­tive mor­tal­ity or ­long-­term sur­vi­val. “Routine” ­use of ­DTS or ­any oth­er ­means of car­diac inves­ti­ga­tion can­not be jus­ti­fied. Patients ­who clin­i­cal­ly ­fall ­into a “­high ­risk” cat­e­go­ry per­haps ­should be inves­ti­gat­ed ­but a ­case ­could be ­made ­for sim­ply optim­is­ing ­their med­i­cal treat­ment ­and ­not car­ry­ing ­out ­either cor­o­nary revas­cu­lar­isa­tion or aneu­rysm ­repair.