The prevalence of coronary artery disease (CAD) in patients with peripheral arterial disease (PAD) varies widely in published reports. This is likely due at least in part to significant differences in how PAD and CAD were both defined and diagnosed. In this report, the investigators describe 78 patients with PAD who underwent preoperative coronary angiography before elective peripheral revascularization and provide a review of published case series. Among the patients included, the number with concomitant CAD varied from 55% in those with lower-extremity stenoses to as high as 80% in those with carotid artery disease. The number of coronary arteries narrowed by ≥50% was 1 in 28%, 2 in 24%, and 3 in 19%; 28% did not have any angiographic evidence of CAD. The review of published research resulted in the identification of 19 case series in which a total of 3,969 patients underwent preoperative coronary angiography before elective PAD surgery; in the 2,687 who were described according to the location of the PAD, 55% had ≥1 epicardial coronary artery with ≥70% diameter narrowing. The highest prevalence of concomitant CAD was in patients with severe carotid artery disease (64%). In conclusion, despite sharing similar risk factors, the prevalence of obstructive CAD in patients with PAD ranges widely and appears to differ across PAD locations. Thus, the decision to perform coronary angiography should be based on indications independent of the planned PAD surgery.
The coexistence of coronary artery disease (CAD) and peripheral arterial disease (PAD) was described nearly 50 years ago. Complications of CAD are the leading causes of postoperative morbidity and mortality in patients who undergo PAD surgery. Therefore, preoperative coronary angiography in patients thought to be at increased risk has become standard clinical practice. Although it is generally assumed that patients with severe PAD have concomitant severe CAD, the prevalence of significant CAD in patients with severe PAD varies widely from 28% to 94% in published reports. This variability is in part attributable to differences in how CAD was defined (≥50% or ≥70% diameter stenosis) and diagnosed (by history alone, electrocardiography, stress testing, or diagnostic coronary angiography) and the location of PAD. When last reviewed in 1994, there were 3 published case series of patients with PAD who underwent preoperative coronary angiography; since then, an additional 16 reports addressing this subject have been published. Given the common assumption that patients with severe PAD also have severe CAD, the inconsistent prevalence estimates across published studies, and the additional information available since last reviewed, we present our own case series of 78 patients who underwent preoperative coronary angiography before PAD surgery and provide an updated review of the previously published reports.
Methods
After receiving approval from our institutional review board, we searched the cardiac catheterization laboratory database at the University of Virginia (Charlottesville, Virginia) for patients with known severe PAD undergoing revascularization surgery who were referred for coronary angiography as part of the preoperative workup from January 1, 2006, to January 1, 2011. We collected demographic and clinical information, including medical history, laboratory values, body mass index, the peripheral vascular territory to be revascularized, and coronary angiographic data. The data were obtained from the electronic medical record and the cardiac catheterization laboratory database. The presence of significant CAD was defined as a ≥70% luminal diameter narrowing of a major epicardial artery or a ≥50% narrowing of the left main coronary artery. We defined PAD as disease documented by a vascular imaging study (including computed tomography, ultrasound, peripheral angiography, and magnetic resonance imaging) that was significant enough for the patient to be referred for elective vascular surgery.
We searched the published research for reported case series of preoperative coronary angiography before PAD revascularization. We reviewed the MEDLINE database (National Library of Medicine, Bethesda, Maryland) and the Cochrane database (Cochrane Library; Wiley InterSciense, Chichester, United Kingdom) for reports published from January 1, 1960, to January 1, 2012. The following key words were used in the search: “peripheral vascular disease,” “PAD,” “CAD,” “concomitant,” “revascularization,” “vasculopath,” “prevalence,” “preoperative,” and “coronary angiography.” The reports reviewed were limited to those written in English. Only case series in which patients were scheduled for peripheral arterial surgery on the basis of vascular imaging studies and underwent coronary angiography as part of their preoperative workup were included. For reports in which the investigators included reviews of the published research, only information from their own primary case series was collected for this review.
Results
From January 1, 2006, to January 1, 2011, 10,696 patients underwent coronary angiography at the University of Virginia cardiac catheterization laboratory. Of these, 78 (0.73%) were referred for the sole purpose of preoperative assessment of coronary anatomy before planned PAD surgery. Most patients were European American, and interestingly, there were more women than men ( Table 1 ). The rates of hypertension and hyperlipidemia were high (88% and 86%, respectively). Although only 35% were current smokers, 72% of the patients had histories of smoking. The most common peripheral vascular territory involved was the abdominal aorta in 50% of the patients ( Table 2 ), and 45% of the patients had significant disease in >1 peripheral arterial territory ( Table 2 ). Angiographic evidence of obstructive CAD (≥70% lesion) was seen in 72% of the patients ( Table 3 ).
| Variable | Value |
|---|---|
| Age (years) | 67 ± 10 |
| Men | 35 (45%) |
| European American | 69 (88%) |
| African American | 7 (9%) |
| Hispanic | 2 (3%) |
| Body mass index (kg/m 2 ) | 27.2 (24.3–30.1) |
| Diabetes mellitus | 26 (33%) |
| Hypertension ⁎ | 69 (88%) |
| Hyperlipidemia † | 67 (86%) |
| Current smokers | 27 (35%) |
| Former smokers | 56 (72%) |
| Glycosylated hemoglobin (%) | 5.4 (0–6.0) |
| Low-density lipoprotein (mg/dl) | 91 (66–111) |
⁎ Patients treated with antihypertensive medication and untreated patients with known systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg.
† Patients with total cholesterol level >200 mg/dl or current use of lipid-lowering drugs.
| Diseased Peripheral Vascular Territory | n (%) |
|---|---|
| Abdominal aortic aneurysm | 39 (50%) |
| Subclavian artery | 7 (9%) |
| Femoral artery | 18 (23%) |
| Carotid artery | 25 (32%) |
| Iliac artery | 29 (37%) |
| Renal artery | 13 (17%) |
| Involvement of >1 territory | 35 (45%) |
| Number of Coronary Arteries Narrowed ≥50% in Diameter | n (%) |
|---|---|
| 1 | 22 (28%) |
| 2 | 19 (24%) ⁎ |
| 3 | 15 (19%) ⁎ |
| 0 | 22 (28%) |
⁎ Three patients with 2-vessel disease and 2 patients with 3-vessel disease had involvement of the left main coronary artery (≥50% stenosis).
Of a total of 58 publications reviewed, 19 fulfilled our search restrictions. The remaining 38 reports were not included for the following reasons: (1) the prevalence of PAD was reported in patients with known CAD; (2) preoperative coronary angiography was performed in patients referred for urgent, not elective, PAD surgery; (3) no definition of CAD was provided; (4) CAD was defined as >50% luminal diameter narrowing, not ≥70% luminal diameter narrowing of a major epicardial artery; (5) PAD surgery was not planned; (6) the strategy of preoperative cardiac testing was not based on coronary angiography; and (7) the report consisted of a subset of patients from a larger, previously published database. These reports were reviewed by 2 of the investigators (D.J.H. and E.C.K.), and pertinent information, including the year the case series was published, the number of patients, gender, age, cardiac risk factors, peripheral vascular territory involved, and coronary angiographic data, were collected and tabulated ( Table 4 ). The 19 case series included patients who underwent elective surgery for abdominal aortic aneurysms, lower-extremity arterial lesions, a combination of abdominal aortic aneurysm and lower-extremity arterial lesions, a combination of abdominal and thoracic aortic aneurysms, carotid artery disease, a combination of abdominal aortic aneurysm and aortoiliac disease, and a combination of all territories, including other areas such as renal and mesenteric arterial disease ( Table 4 ). Except for 1 series that reported a predominance of women similar to ours, most patients in the remaining 19 case series were men. Even when restricting the definition of CAD to the presence of a ≥70% lesion in ≥1 major epicardial coronary artery, the number of patients with concomitant CAD in these case series varied from as low as 28% in patients with abdominal aortic aneurysms to as high as 94% in patients with obstructive carotid artery disease.
| Study | Number of Patients | Men/Women | Age (years), Mean (Range) | Smokers | Hypertension | Diabetes | Hyperlipidemia | Peripheral Territory | Significant CAD § |
|---|---|---|---|---|---|---|---|---|---|
| Tomatis et al (1972) | 100 | 83 (83%)/17 (17%) | 61 (39–81) | 95 (95%) | 48 (48%) | 14 (14%) | 36 (36%) | AAA (n = 28), LE (n = 72) | 21/28 (75%); 34/72 (47%) |
| Blombery et al (1987) | 84 | 63 (75%)/21 (25%) | 66 (51–79) | 53 (63%) | 54 (64%) | 30 (36%) | 37 (44%) | AAA | 30/39 ⁎ (76%) |
| Acinapura et al (1987) | 42 | 39 (93%)/3 (7%) | 67 (49–78) | NR | 15 (36%) | 6 (14%) | NR | AAA | 36 (86%) |
| Aoshima et al (1992) | 37 | 33 (89%)/4 (11%) | 68 (53–76) | 23 (62%) | 20 (54%) | 14 (38%) | 15 (41%) | AAA (n = 16), LE (n = 21) | 7/16 (44%); 12/21 (57%) |
| Hertzer et al (1984) | 1,000 | 685 (69%)/315 (31%) | 64 (29–95) | NR | 548 (55%) | 170 (17%) | NR | AAA (n = 263), carotid (n = 295), LE (n = 381), other (n = 61) † | 170/263 (65%); 174/295 (59%); 218/381 (57%); 36/61 (59%) |
| Bayazit et al (1995) | 125 | 21 (17%)/104 (83%) | 64 (38–83) | NR | 63 (50%) | 19 (15%) | NR | AAA | 35 (28%) |
| Kishi et al (1997) | 102 | 82 (80%)/20 (20%) | 68 (48–83) | 47 (46%) | 61 (60%) | 10 (10%) | 37 (36%) | AAA | 66 (65%) |
| Deville et al (1997) | 283 (151 ⁎ ) | 259 (92%)/24 (8%) | 72 (45–92) | NR | 90 (32%) | NR | NR | AAA | 52 (34%) |
| Utoh et al (1998) | 50 | 46 (92%)/4 (8%) | 71 | 41 (82%) | 29 (58%) | 9 (18%) | 21 (42%) | AAA | 23 (46%) |
| Kieffer et al (2002) | 133 (84 ⁎ ) | 116 (87%)/17 (13%) | 66 (39–84) | NR | NR | NR | NR | TAA (n = 45), AAA (n = 88) | 36 (43%) |
| Kioka et al (2002) | 94 | 81 (86%)/13 (14%) | 72 | 55 (94%) | 68 (72%) | 14 (15%) | 31 (34%) | AAA | 43 (46%) |
| Takahashi et al (2002) | 159 (145 ⁎ ) | 132 (83%)/27 (17%) | 70 (53–87) | NR | 59 (41%) | 15 (10%) | 18 (12%) | AAA | 43 (30%) |
| Sasaki et al (2004) | 100 | 89 (89%)/11 (11%) | 71 (56–87) | 58 (58%) | 65 (65%) | 7 (7%) | 45 (45%) | AAA | 47 (47%) |
| Hofmann et al (2005) | 420 | 276 (66%)/144 (34%) | 69 | 54 (13%) | 306 (73%) | 118 (28%) | 282 (67%) | Carotid | 258 (61%) |
| Shimada et al (2005) | 200 (78 ⁎ ) | 175 (87%)/25 (13%) | ≥70 ‡ | 136 (68%) | 153 (77%) | 72 (36%) | 89 (45%) | Carotid | 73 (94%) |
| Her et al (2008) | 82 | 61 (74%)/21 (26%) | 68 (47–88) | 50 (61%) | 53 (65%) | 56 (68%) | 24 (29%) | LE | 27 (33%) |
| Hosokawa et al (2008) | 122 | 106 (87%)/16 (13%) | 73 | 58 (48%) | 96 (79%) | 15 (12%) | 47 (39%) | AAA | 68 (56%) |
| Garcia et al (2008) | 1,048 (823 ⁎ ) | NR | NR | NR | NR | NR | NR | AAA, LE | 626 (76%) |
| Monaco et al (2009) | 208 (105 ⁎ ) | 75 (71%)/30 (29%) | 74 | NR | 70 (67%) | 39 (37%) | NR | AAA, LE | 65 (62%) |
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