Ann Thorac Surg 2004;78:470
© 2004 The Society of Thoracic Surgeons
Invited commentary
Norman Hertzer, MD
Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
e-mail: hertzen{at}ccf.org
From my standpoint as a vascular surgeon, there always have been two good reasons to correct severe coronary artery disease before proceeding with the surgical management of peripheral arterial disease (PAD). First, this approach presumably reduces the risk for early postoperative cardiac events or death that historically have been associated with major noncardiac vascular procedures, such as aortic reconstruction for aneurysms or lower extremity ischemia. Second, and sometimes overlooked, it also may enhance long-term survival in a patient population whose high cardiac mortality rate occasionally calls into question whether it was worthwhile to treat their PAD surgically in the first place. The early postoperative risk of these patients has been improved substantially by the protective effect of beta blockade, and now by the ability to repair aortic aneurysms as well as occlusive lesions using minimally invasive endovascular techniques. Therefore, late survival predictably will become the principal metric by which the future success of either percutaneous coronary intervention (PCI) or coronary bypass grafting is determined in PAD patients, and that makes this article by O'Rourke and colleagues from the Northern New England Cardiovascular Disease Study Group especially interesting.
There is nothing quite like an internal thoracic graft to the anterior descending coronary artery to generate optimism that a patient who otherwise is an acceptable surgical candidate probably will live long enough to justify whatever operations eventually become necessary for PAD. Unless it took place very recently, however, a history of PCI may not always promote the same level of confidence. While the data from Northern New England could loosely be interpreted to support this bias, they do not include patients with aortic aneurysms and the authors have been careful to point out several features that could not be adjusted for case mix in their multivariate statistical model. Perhaps most importantly, their series was collected from 1994 through 1996 and contains a large but unspecified number of patients who underwent PCI without intraluminal stenting. By all accounts, that simply does not reflect the durability of PCI as it presently is performed. Furthermore, the fact that nearly 30% of the PCI patients in this series already had undergone coronary bypass grafting leads inevitably to the question of whether the superior survival rate in the surgical cohort might be attributable in some measure to PCI itself. In summary, this work is stimulating but does not yet prove that modern PCI and coronary artery bypass surgery are any less complementary in patients with PAD than they are in other patients who have ischemic heart disease.
