Negative impact of cardiac evaluation before vascular surgery

The optimal preoperative evaluation of cardiac risk in patients with periph eral vascular disease is controversial. In developing a paradigm for preope rative cardiac workup, potential adverse effects of evaluation and cardiac intervention must be considered. This study analyzed the deleterious outcom es of extensive, comprehensive cardiac evaluation and intervention before p lanned vascular surgery in patients treated at the Denver Department of Vet erans Affairs Medical Center. Over a 12-month period between 1994 and 1995, 161 patients were scheduled t o undergo major vascular operations; 153 patients came to operation. The de cision to pursue a cardiac evaluation was variously made by a combination o f surgeons, cardiologists, and anesthesiologists. No defined protocol was f ollowed. Cardiac history, chest X-rays and ECGs were obtained for all patie nts. Extended cardiac evaluation included these studies plus special tests, including echocardiography (echo), radionuclide ventriculography (RNVG), d ipyridamole thallium scintigraphy (DTS), and cardiac catheterization (CC). Extended cardiac evaluations were undertaken in 42 patients. Complications related to percutaneous transluminal coronary angioplasty (PTCA) and corona ry artery bypass grafting (CABG) were also recorded. Cardiac mortality and morbidity after vascular interventions were itemized in all 153 patients. Forty-two male patients, aged 68 +/- 9 years, underwent extended cardiac ev aluations before planned vascular operations. The median elapsed time for c ardiac workup was 14 days (mean 30 +/- 59 days). The median and mean times from cardiac workup to vascular surgery were 25 days and 76 +/- 142 days, r espectively. Eighteen (43%) patients had echo or RNVG; 22 (52%) patients ha d DTS; 27 (64%) had CC; 9 (21%) had PTCA; 7 (17%) had CABG. Sixteen (38%) p atients had untoward events related to cardiac evaluation. Eight patients ( 19%: one with cerebrovascular disease, and seven with aortic aneurysms) ref used Vascular surgery after extended cardiac workup. Complications attribut able to CC, PTCA, and CABG included prosthetic graft infection, pseudoaneur ysms (two), sternal wound infections (two), renal failure and brain anoxia. Two patients with severe limb ischemia who were candidates for revasculari zation ultimately required amputations because of delay due to cardiac eval uations. Extensive cardiac evaluation prior to vascular operations can result in mor bidity, delays, and refusal to undergo vascular surgery. The underlying ind ication for vascular operations and the local iatrogenic cardiac complicati on rates must be considered before ordering special studies.