A multidisciplinary approach in determining of prevalence of coronary artery disease and treatment strategies in patients with pathology of the aorta and peripheral arteries

The treatment of coronary artery disease (CAD) in patients with combined pathology of peripheral arteries who are to perform endovascular or surgical interventions is a difficult task. The most important issues are the adequate diagnostics of artery systems’ lesions, determining the most optimal strategy and stages of treatment. This makes a multidisciplinary approach with the involvement of various specialists the most optimal.

Aim. Based on multidisciplinary approach, to determine the prevalence of CAD and treatment strategy in patients with lesions of the aorta and peripheral arteries.

8

Material and methods. The study included 693 patients with pathology of the aorta and peripheral arteries: 171 (32,5%) were female, and 522 (75,3%) were male. The age of patients ranged from 29 to 93 years, an average — 67,2+8,8 years. Also 32,5% of patients (n=223) were older than 71 years. Cardiac complaints were present only in 203 (29,3%) patients, while 490 (70,7%) were asymptomatic. The majority of 693 patients had an isolated lesion of the internal carotid artery (ICA) (n=196, 28,3%), a combined lesion of the ICA and lower limb arteries (n=93, 13,4%), a combined lesion of the iliac and superficial femoral arteries (n=70, 10,1%) and femoral arteries lesions (n=60, 8,6%).

Results. Finally, 554 (79,9%) of 693 patients had lesions of at least one coronary artery more than 50%, while 368 (66,4%) of them were clinically asymptomatic. By the decision of the multidisciplinary heart team, 316 (57,0%) patients underwent myocardial revascularization operations: 21 (6,7%) — coronary artery bypass grafting and 295 (50,3%) — percutaneous coronary intervention. Surgical and endovascular operations for pathology of the aorta and peripheral arteries were performed in 486 (70,1%) of 693 patients. Unlike with 260 (53,5%) patients, in 226 (46,5%) patients, in addition to vascular surgery, myocardial revascularization was performed. As a result of 923 (564 endovascular and 359 surgical) operations performed in 580 patients at the hospital stage, 3 (0,51%) of them had a fatal outcome. In other 2 (0,56%) cases, there was stroke: in one case after ICA prosthetics, in the other case — thrombosis of the ICA after the carotid endarterectomy. Acute myocardial infarction at the hospital stage was not detected in any of the patients.

Conclusion. In 79,9% of patients with atherosclerosis of the aorta and peripheral arteries, at least one coronary artery lesion of more than 50% is detected. In 66,4% of patients with pathology of the aorta and peripheral arteries and with lesions of the coronary arteries of more than 50%, there are no cardiac complaints. In 45,6% of patients hospitalized with a diagnosis of atherosclerotic lesions of the aorta and peripheral arteries, myocardial revascularization is required. A multidisciplinary approach is an effective and safe treatment strategy for patients with pathology of the aorta and peripheral arteries of atherosclerotic origin and concomitant CAD.

1. Update, O. O. (2017). Organization for Economic Cooperation and Development (OECD), 2017. http://www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm.

2. Global, regional, and national age sex specific all-cause and cause specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385:117.

3. Global atlas on cardiovascular disease prevention and control. Geneva: World Health Organization (WHO); 2011. https://www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/.

4. Nichols M, Townsend N, Luengo-Fernandez R, et al., European Cardiovascular Disease Statistics, European Heart Network, Brussels, 2012 (European Society of Cardiology, Sophia Antipolis). https://www.escardio.org/static_file/Escardio/Press-media/pressreleases/2013/EU-cardiovascular-disease-statistics-2012.pdf.

5. Nadareishvili ZG, Rothwell PM, Beletsky V, et al. Long-term risk of stroke and other vascular events in patients with asymptomatic carotid artery stenosis. Archives of neurology. 2002;59(7):1162-6.

6. Hertzer NR, O’hara PJ, Mascha EJ, et al. Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: the Cleveland Clinic experience from 1989 to 1995. Journal of vascular surgery. 1997;26(1):1-10.

7. Salasidis GC, Latter DA, Steinmetz OK, et al. Carotid artery duplex scanning in preoperative assessment for coronary artery revascularization: the association between peripheral vascular disease, carotid artery stenosis, and stroke. Journal of vascular surgery. 1995;21(1):154-62.

8. Illuminati G, Schneider, F, Greco C, et al. Long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease. European Journal of Vascular and Endovascular Surgery. 2015;49(4):366-74.

9. Migliorino D, Mignano A, Evola S, et al. Correlation between carotid atherosclerosis and coronary artery disease: A retrospective study of 1067 patients. Nutrition, Metabolism and Cardiovascular Diseases. 2017;27(1):e28.

10. Aboyans V, Ricco JB, Bartelink MLE, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases. European heart journal. 2017;39(9):763-816.

11. Alekyan BG, Grigoryan AM, Staferov AV, Karapetyan NG. Roentgen-vascular diagnostics and treatment of cardiovascular diseases in Russian Federation 2018. Endovascular surgery. 2019;6(2):188, Special edition. (In Russ.)

12. Alekyan BG, Grigoryan AM, Staferov AV, Karapetyan NG. Roentgen-vascular diagnostics and treatment of cardiovascular diseases in Russian Federation 2017. Endovascular surgery. 2018;5(2):93-240. (In Russ.)

13. Bokeria LA, Gudkova LA, Milievskaya EB, et al. Cardiovascular surgery 2107. Bolezni I vrozhdennye anomalii sistemy krovoobraschenija. NMICSSH AN Baculev. 2018. 228 p. (In Russ.)

14. Cohen MC, Aretz TH. Histological analysis of coronary artery lesions in fatal postoperative myocardial infarction. Cardiovasc Pathol. 1999;8:133-9.

15. Mangano DT. Adverse outcomes after surgery in the year 2001 — a continuing odyssey. Anesthesiologyю 1998;88:561-4.

16. Roger VL, Ballard DJ, Hallett JW Jr, et al. Influence of coronary artery disease on morbidity and mortality after abdominal aortic aneurysmectomy: a population-based study, 19711987. J Am Coll Cardiol. 1989;14:1245-52.

17. Farkouh ME, Rihal CS, Gersh BJ, et al. Influence of coronary heart disease on morbidity and mortality after lower extremity revascularization surgery: a population-based study in Olmsted County, Minnesota (1970-1987). J Am Coll Cardiol. 1994;24:1290-6.

18. Rihal CS, Gersh BJ, Whisnant JP, et al. Influence of coronary heart disease on morbidity and mortality after carotid endarterectomy: a population-based study in Olmsted County, Minnesota (1970-1988). J Am Coll Cardiol. 1992;19:1254-60.

19. Kesson EM, Allardice GM, George WD, et al. Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 2012;344:e2718.

20. Ray-Coquard I, Thiesse P, Ranchere-Vince D, et al. Conformity to clinical practice guidelines, multidisciplinary management and outcome of treatment for soft tissue sarcomas. Ann Oncol. 2004;15:307-15.

21. Kolh P, Wijns W, Danchin N, et al. Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2010;3.8:S1-S52.

22. Kristensen SD, Knuuti J, Saraste A, et al 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. European heart journal. 2014;35(35):2383-431.

23. Patel MR, Dai D, Hernandez AF, et al. Prevalence and predictors of nonobstructive coronary artery disease identified with coronary angiography in contemporary clinical practice. American heart journal. 2014;167(6):846-52.

24. Alekyan BG, Pokrovsky AV, Karapetyan NG, et al. The results of endovascular treatment of patients with complex lesion coronary and internal carotid arteries. Endovascular surgery. 2019;6(1):20-6. (In Russ.)