title: Morbidity and mortality caused by cardiac adverse events after revascularization for critical limb ischemia.
abstract: BACKGROUND
  We assessed cardiac adverse events (AEs) after primary lower extremity arterial revascularization (LEAR) for critical lower limb ischemia (CLI) in order to evaluate the impact of cardiac AEs on the clinical outcome. We created an optimized care protocol concerning CLI patients' preoperative work-up as well as intra- and postoperative surveillance according to recent important literature and guidelines.
  
  
  METHODS
  We conducted a prospective analysis of clinical outcome after LEAR using patient-related risk factors, comorbidity, surgical therapy, and AEs. This cohort was divided into patients with and without AEs. AEs were categorized according to predefined standards: minor, surgical, failed revascularization, and systemic. The consequences of AEs were reoperation, additional medication, irreversible physical damage, and early death.
  
  
  RESULTS
  There were 106 patients (Fontaine III n=49, 46%, and Fontaine IV n=57, 56%) who underwent primary revascularization by bypass graft procedure (n=67, 63%) or balloon angioplasty (n=39, 37%). No difference in comorbidity was registered between the two groups. Eighty-four AEs were registered in 34 patients (32%). Patients experiencing AEs had significantly less antiplatelet agents (without AEs n=63, 88%, vs. with AEs n=18, 53%; p=0.000) and/or beta-blockers (without AEs n=66, 92%, vs. with AEs n=16, 47%; p=0.000) compared to patients without AEs. The two most harmful consequences of AEs were irreversible physical damage (n=3) and early death (n=8). Sixty percent (n=9) of systemic AEs were heart-related. The postprocedural mortality rate was 7.5%, with a 75% (n=6) heart-related cause of death.
  
  
  CONCLUSIONS
  AEs occur in >30% of CLI patients after LEAR. The most harmful AEs on the clinical outcome of CLI patients were heart-related, causing increased morbidity and death. Significant correlations between prescription of beta-blockers and antiplatelet agents and prevention of AEs were observed. A persistent focus on the prevention of systemic AEs in order to ameliorate the outcome after LEAR for limb salvage remains of utmost importance. Therefore, we advise the implementation of an optimized care protocol by discussing patients in a strict manner according to a predetermined protocol, to optimize and standardize the preoperative work-up as well as intra- and postoperative patient surveillance.
authors.affiliation: Department of Vascular Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands.
authors.forename: H C
authors.initials: HC
authors.lastname: Flu
authors.forename: J H P
authors.initials: JH
authors.lastname: Lardenoye
authors.forename: E J
authors.initials: EJ
authors.lastname: Veen
authors.forename: A E
authors.initials: AE
authors.lastname: Aquarius
authors.forename: D P
authors.initials: DP
authors.lastname: Van Berge Henegouwen
authors.forename: J F
authors.initials: JF
authors.lastname: Hamming
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D000800:Angioplasty, Balloon / Q000009:adverse effects* / Q000401:mortality; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D002985:Clinical Protocols; D016638:Critical Illness; D005260:Female; D006331:Heart Diseases / Q000209:etiology* / Q000401:mortality / Q000517:prevention & control; D006801:Humans; D033183:Interdisciplinary Communication; D007511:Ischemia / Q000209:etiology / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D018579:Patient Selection; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011446:Prospective Studies; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000401:mortality
chemical_list: D000319:Adrenergic beta-Antagonists; D010975:Platelet Aggregation Inhibitors