title: Coronary-artery revascularization before elective major vascular surgery.
abstract: BACKGROUND
  The benefit of coronary-artery revascularization before elective major vascular surgery is unclear.
  
  
  METHODS
  We randomly assigned patients at increased risk for perioperative cardiac complications and clinically significant coronary artery disease to undergo either revascularization or no revascularization before elective major vascular surgery. The primary end point was long-term mortality.
  
  
  RESULTS
  Of 5859 patients scheduled for vascular operations at 18 Veterans Affairs medical centers, 510 (9 percent) were eligible for the study and were randomly assigned to either coronary-artery revascularization before surgery or no revascularization before surgery. The indications for a vascular operation were an expanding abdominal aortic aneurysm (33 percent) or arterial occlusive disease of the legs (67 percent). Among the patients assigned to preoperative coronary-artery revascularization, percutaneous coronary intervention was performed in 59 percent, and bypass surgery was performed in 41 percent. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the group not undergoing revascularization (P<0.001). At 2.7 years after randomization, mortality in the revascularization group was 22 percent and in the no-revascularization group 23 percent (relative risk, 0.98; 95 percent confidence interval, 0.70 to 1.37; P=0.92). Within 30 days after the vascular operation, a postoperative myocardial infarction, defined by elevated troponin levels, occurred in 12 percent of the revascularization group and 14 percent of the no-revascularization group (P=0.37).
  
  
  CONCLUSIONS
  Coronary-artery revascularization before elective vascular surgery does not significantly alter the long-term outcome. On the basis of these data, a strategy of coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended.
authors.affiliation: Minneapolis Veterans Affairs Medical Center, Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis 55417, USA. mcfal001@tc.umn.edu
authors.forename: Edward O
authors.initials: EO
authors.lastname: McFalls
authors.forename: Herbert B
authors.initials: HB
authors.lastname: Ward
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Moritz
authors.forename: Steven
authors.initials: S
authors.lastname: Goldman
authors.forename: William C
authors.initials: WC
authors.lastname: Krupski
authors.forename: Fred
authors.initials: F
authors.lastname: Littooy
authors.forename: Gordon
authors.initials: G
authors.lastname: Pierpont
authors.forename: Steve
authors.initials: S
authors.lastname: Santilli
authors.forename: Joseph
authors.initials: J
authors.lastname: Rapp
authors.forename: Brack
authors.initials: B
authors.lastname: Hattler
authors.forename: Kendrick
authors.initials: K
authors.lastname: Shunk
authors.forename: Connie
authors.initials: C
authors.lastname: Jaenicke
authors.forename: Lizy
authors.initials: L
authors.lastname: Thottapurathu
authors.forename: Nancy
authors.initials: N
authors.lastname: Ellis
authors.forename: Domenic J
authors.initials: DJ
authors.lastname: Reda
authors.forename: William G
authors.initials: WG
authors.lastname: Henderson
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000401:mortality; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000601:surgery; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000601:surgery; D001026:Coronary Artery Bypass / Q000401:mortality; D003327:Coronary Disease / Q000150:complications / Q000188:drug therapy / Q000628:therapy*; D017558:Elective Surgical Procedures / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011300:Preoperative Care; D016016:Proportional Hazards Models; D016019:Survival Analysis; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000401:mortality*