Risks of Preoperative PCI

Decision analyses have suggested that coronary angi-ography and intervention before vascular surgery should be carried out only if the risk of the vascular surgery is relatively high (>5% mortality risk) and the anticipated risk of angiography and revascular-ization is relatively low (<3% mortality risk). However, many studies have demonstrated that the short- and long-term risks of performing PCI are substantially increased among patients with comorbidities requiring noncardiac surgery, especially if PCI is performed in individuals with concomitant peripheral vascular disease. Among 2340 patients enrolled in the BARI trial or registry, the presence of peripheral vascular disease was associated with a 50% relative increase in major in-hospital cardiovascular events after PCI (11.7% vs. 7.8%) and an almost twofold increased likelihood of adverse events after CABG. Similarly, within another large registry of 25,114 patients who underwent PCI between 1997 and 2001, the presence of peripheral or cerebral artery disease was independently associated with significantly increased likelihoods of in-hospital death (2.8% vs. 1.3%), MI (3.0% vs. 2.0%), stroke (0.8% vs. 0.3%), nephropathy (3.3% vs. 0.8%), major vascular complications (3.4% vs. 2.2%), and need for blood transfusion (8.2% vs. 4.2%).33 Likewise, among 7696 patients who underwent coronary stenting at the Mayo Clinic, concomitant peripheral arterial disease was associated with an independent, nearly twofold increase in the likeli hood of in-hospital death, as well as a significantly increased composite event rate of death, MI, CABG, or target vessel revascularization at 2 years.34 The significantly elevated risks of performing PCI in the setting of coexisting peripheral vascular disease, as highlighted by these studies, should be considered when deciding whether to undertake PCI in patients with planned vascular surgery.

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