February 1999

I picked this editorial because I know Lee and Paul, and they're smarter than your average bear. When Fleisher and Barash talk, people listen (they're like Merrill Lynch). They review a mediocre article by Gottlieb et al which looks at the Cleveland Clinic's database on people who got angioplastied before their vascular surgery. [1] Gottlieb and colleagues conclude, with little real evidence from the study, that PTCA before cardiac surgery probably IS protective. Unfortunately, we will need a prospective study to prove it before we suggest that interventional cardiology is as good as a CABG in terms of decreasing cardiac risk before vascular surgery.

The editorialists note that it is unclear why PTCA should theoretically result in a great decrease in perioperative events. Only about a third of events are related to the critical stenoses that PTCA would address. The other infarcts occur with little, or only moderate, stenosis and wouldn't be protected against by angioplasty. Fleisher and Barash conclude that the present study does NOT answer the questions for whom, how far in advance of surgery (i.e., when), or even whether preoperative angioplasty is good. One has to measure the possible benefits against the intervention's attributable morbidity.

So, we still don't know, but suspect, that clinically indicated PTCA preoperatively does reduce perioperative MI risk. I hope that this information helps those of you who face the question, "Should we consider preoperative angioplasty for high risk cardiac patients if indicated?" Personally, I think preoperative angioplasty can be a good idea, keeping in mind that there are two high risk times for reocclusion, early and late, which can potentially complicate the perioperative course. But my practice is based more on gestalt than fact. The fact that Fleisher and Barash tend to agree makes me feel a whole lot better.

References

1. Gottlieb A; Banoub M; Sprung J; Levy PJ; Beven M; Mascha EJ. Perioperative cardiovascular morbidity in patients with coronary artery disease undergoing vascular surgery after percutaneous transluminal coronary angioplasty. J Cardiothorac Vasc Anesth. 1998 Oct;12(5):501-506.

Return to the Current Literature Review Front Page