CASE REPORT

Preoperative Management in Patient

with Concomitant Acute Limb Ischemia
and Coronary Artery Disease

Gunawan

Major manifestations of atherothrombosis

include
Cerebrovascular disease
Coronary artery disease
Renal artery stenosis
Visceral arterial disease
Peripheral arterial disease
Intermittent claudication
Critical limb ischemia
Acute imb ischemia

CASE

Case
Identity
Name : Mr. S
Age
: 68 yo
Address: Jakarta
Chief Complaint :
Sudden exaggerating pain in the left foot
since 3 days before admission

Case
14 days earlier

7 days earlier

4 days earlier

Chest tightness (+)

Numbness and
cramp of his left
foot

Felt continuous
sharp pain on his
left leg even at
resting or at walking

Duration + 5 min
Sweating (+)
Did not aggravate
by activity
Reduce by itself
Palpitation (+)

Did not augmented

by activity
Went to the
traditional massage
did not improved
Pale legs skin
Numbness and
cramp did not
relieved
Weakness (+)

He felt his leg were

cold and weak
He loss his sensory
from his left leg and
then he barely
cannot move his
left leg
his left legs skin
color starting to
change darker

Case
2 days earlier
He suffered wound
at his foot and
slight fever since
then
There were
scalloping skin at
his feet
He went to
paramedic near
from his house to
have first help
his leg already
dead and had to
undergone surgery.

2 days earlier
He suggested by
the doctor to go to
the hospitals, but
because of financial
problems, he did
not go to the
hospital

1 days earlier
He got all day slight fever
accompanied by productive
cough, the sputum color
were white.
His urinating were fine,
there were not any pain,
red urine color, or sandy
feel during urinating.
The urine output was
decreasing because patient
did not eat well.
He went to Cipto
Mangunkusumo
emergency room because
he cannot stand for the
pain again

Case

He had already smoked cigarette for 20 years, one

pack a day and he stopped just about 5 year ago
There were no sign of polyuria, polydipsia, and
polyfagia in this patient
From previous history of illness, we did not find any
heart problems, lung diseases, or kidney problems.
Patient had uncontrolled hypertension that known
from the last 5 years, he only consumed captopril
when he feel dizzy. The highest blood pressure ever
recorded was 180/100 mmHg.

Case

Physical examination on ER

Alert, looked very ill and weak

Vital signs : BP : 120/80 mmHg; HR : 98 bpm; RR : 24x/min;
temp : 36.8 C
Eye
: Pale conj (-), Icteric sclera (-)
Neck
: JVP 5-2 cmH2O, lymph node (-)
Lung
: Ves, rales lower 3rd lung, wh (-)
Cor
: Heart sound (N), cardiomegaly (-)
Abd
: enlargement of liver/spleen (-), epigastric
tenderness (+)
Ext
: left leg : ischemia, necrotic up until 1/3 upper
thigh , gangrenes at 1st fingers, paralyze (+), sensory
(-)
Right leg : normal, ABI 0.9, pallor (-), motoric (+),
sensory (+)

Case

left leg :
ischemia, necrotic up
until 1/3 upper thigh ,
gangrenes at all
fingers, paralyze (+),
sensory (-)

Case
Laboratory Parameter
Hb
Ht
Leukocyte
Thrombocyte
MCV
MCH
MCHC

Value
12.5 g/dL
36 %
36.200/mL
604.000/mL
80 pg
27 fl
34 g/dL

Case
Laboratory
Parameter

Value

Laboratory
Parameter

Value

Creatinin

1.4 mg/dL

pH

7.499

AST

164 mg/dL

pCO2

Albumin

2.9 mg/dL

pO2

169

Glucose

155 mg/dL

HCO3

24.3

Sodium

134 mEq/L

Be

Potassium

3.6 mEq/L

Sat O2

Chloride

98 mEq/L

31

0.9
98.3

Case
Laboratory Parameter
Epithel

Value

Laboratory Parameter
+

Bilirubin

Value
-

Leukocyte

1-2

Urobilinogen

0.2

Erythrocyte

1-2

Nitrit

Cylinder

Esterase leukocyte

Crystal

Etc

Bacteria

CK

663

Trop T

1.3

pH

5.0

BJ

1.020

Prot

PT

14 (13)-1.07

Glucose

aPTT

58 (34)-1.75

Blood/Hb

Fibrinogen

524

D-dimer

320

Case

ECG
Sinus tachycardia,
LAD, Q wave V1-V3,
ST elevation V2-V4,
VES (+), LVH (-), RVH
(-), BBB (-)

Case

Chest Xray

Aortic elongation &

calcification

Left leg

Normal

Case

Problems
Acute limb ischemia
Community acquired Pneumonia
Hypertension JNC VII stg II
OMI and VES

Treatment :

Surgery Dept : no emergency procedure

O2
Semi trandelendburg position
Heparin infusion target aPTT 2-3x control
Aspirin 1x80 mg
Amiodarone 3x200 mg
Cilostazol 1x50 mg
Captopril 2x12.5 mg
Antibiotic
Internal Medicine ward evaluation

Case

Day 2 of treatment
The pain (+), with ascending necrosis of left leg
approximately 5 centimeter. Patient felt
shortness of breath, and there was productive
cough,
He got fever 37.5 C and dyspneu with
respiratory rate of 24 times/minutes.
The jugular vein pressure was elevated to 5+0
cmH2O, rales with wheezing on both lung,

Case
Laboratory Parameter

Value

Hb

13.5 g/dL

Ht

41.5 %

Leukocyte
Thrombocyte

31.700/mL
801.000/mL

MCV

84 pg

MCH

27 fl

MCHC

32 g/dL

Laboratory
Parameter

Value

Laboratory
Parameter

Creatinin

1.5 mg/dL

PT

Ureum

66 mg/dL

aPTT

AST

194 mg/dL

LED

ALT

169 mg/dL

Sodium

129 mEq/L

Potassium

4.29 mEq/L

Chloride

104 mEq/L

Value
16.3 (12.7)-1.2
42 (33.4)-1.2
106

Case

We assessed patient at state of congestive heart

failure NYHA functional class 3 and acute renal
failure.
Furosemide 40 mg once daily added to improve
the condition.
Water input and output was balanced to repair
the damage on kidney.
Patient scheduled to have arteriography at that
day, but because of lack of human resource, the
arteriography was aborted, and heparinization
was continued.

Case

3rd day of admission

patient underwent arteriography,
corangiography and echocardiography.
Result echo :
Thrombus apical LV (+) 0.8x1.8cm
Akinetic apical LV, ant wall, septal
MR mild, TR mild, AR mild, PH mild
EF 30%

Case

Total occlusion a.
femoralis comm
Non visualized a.
femoralis superficial &
profunda tibialis
Collateral 1/3 prox

Case

LAD
LAD proximal 100%
stenosis
Thrombus (+)

Case

LCX
Stenosis 90 % LCX
proximal, OM 1 95%
stenosis, LCX distal
90% stenosis

Case

RCA
Irregular, collateral
RCA distal to LCX
distal and LAD distal

Case

Patient prepared to underwent PTCA and stent

placement before amputation.
After patient return to the ward, patient was in
sepsis condition because he got tachycardia,
dyspneu and fever, with probable focus of
infection gangrenous ulcer of left leg or
pneumonia.
We decided to monitor the patient condition
closely by paying attention to hydration balance
and vital sign observation.

Case

The vascular surgeon decided to

amputate the left leg above knee at once.
Preoperative risk assessment from
internal medicine was at high risk and lots
of complication might occur. After proper
inform consent with the family, the
surgeon decided to amputate the left leg.

Case

Patient then underwent amputation at the ER

operating room at 2 oclock in the morning. After
operation, at 4 oclock, patient went to Intensive
Care Unit.
Patient condition was not stable back then, he
suffered for recurrent ventricular tachycardia and
fibrillation. After receiving 5-hour intensive
treatment at ICU, patient passed away with
cause of death was cardiac arrest.

DISCUSSION

Atherothrombosis: A Generalized and

Progressive Process

Normal

Fatty
streak

Fibrous
plaque

Atherosclerotic
plaque

Plaque
rupture/
fissure &
thrombosis

Unstable
angina

ACS
MI
Ischemic
stroke/TIA

Acute limb
ischemia

Increasing age

Stable angina
Intermittent claudication

ACS=acute coronary syndrome; TIA=transient ischemic attack

Rauch U. Ann Intern Med. 2001;134:224-238; Yeghiazarians Y. N Engl J Med. 2000;342:101-114

Cardiovascular
death

Concomitant Artery Disease

8.4%

Coronary artery
disease44.6

1.6
%

Cerebral artery
disease
16.6
%
1.2%

4.7%
PAD
4.7%
Bhatt DL, et al. International prevalence,
recognition, and treatment of cardiovascular
risk factors in outpatients with

Risk factors for PAD

Gender (male)
Age

PAD

Smoking
Hypertension
Diabetes
Hyperlipidaemia
Fibrinogen
Homocysteinaemia

Atherosclerosis

Atherothrombosis

Ischaemic
stroke

Myocardial
infarction

Murabito JM et al. Circulation 1997;96:4449; Laurila A et al. Arterioscler Throm Vasc Biol 1997;17:29102913;
Malinow MR et al. Circulation 1989;79:11801188; Brigden ML. Postgrad Med 1997;101:249262.

Natural History of PAD

Age > 50 years
Cardiovascular
Morbidity /
Mortality

Limb
Morbidity

Stable
Claudication
70-80%

Worsening
Claudication
10-20%

Critical
Limb
Ischemia
1-2%

Nonfatal
CV Events
20%

CV Causes
75%

Mortality
15-30%

Non CV Causes
25%

Identification of the Symptomatic

Patient with Acute Limb Ischemia

The hallmark clinical symptoms and physical

examination signs of acute limb ischemia
include the 5 Ps that suggest limb jeopardy:

pain, paralysis, paresthesias, pulselessness, and pallor

(and perhaps a sixth P, polar).

Acute arterial embolism is suggested by:

the sudden onset or sudden worsening of symptoms

a known embolic source
the absence of antecedent claudication or other
manifestations of obstructive arterial disease, or
the presence of normal arterial pulses and Doppler
systolic blood pressures in the contralateral limb.

Rutherford Classification
Doppler

Category

Description

Cap. refill

Paralysis

Sensory
loss

I
IIa
IIb

Viable

Not immediately
threatened

Intact

Aud

Aud

Threatened

Salvagable if
treated

Intact/slow

Partial

Aud

Threatened

Salvagable if
treated
emergently

Slow/absen
t

Partial

Partial

Aud

III

Irreversible

Primary
amputation req.

Absent

Complete

Complete

Treatment of Acute Limb Ischemia (ALI)

Severe PAD documented:
ABI less than 0.4; flat PVR waveform; absent pedal flow

Immediate anticoagulation:
Unfractionated heparin or low molecular weight heparin

Obtain prompt vascular specialist

consultation:
Diagnostic testing strategy
Creation of therapeutic intervention plan

Assess etiology:
Embolic (cardiac, aortic, infrainguinal sources)
Progressive PAD & in situ thrombosis (prior claudication
history)
Leg bypass graft thrombosis
Arterial trauma
Popliteal cyst or entrapment; Phlegmasia cerulea dolens
Ergotism; Hypercoagulable state

Contd
ABI=ankle-brachial index; PVR=pulse-volume recording.

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Treatment of Acute Limb Ischemia (ALI)

Assess etiology

Viable limb
(Not
immediately
threatened)
No sensory loss
No muscle
weakness
Audible arterial
and venous US

Salvageable limb: threatened

marginally
(reversible ischemia)
Salvageable if promptly treated
Minimal (toes) or no sensory
loss
No muscle weakness
Inaudible (often) arterial
Doppler signals
Audible venous Doppler
signals

Salvageable limb: threatened

immediately
(reversible ischemia)
Salvageable with immediate
revascularization
Sensory loss > toes with rest
pain
Mild to moderate muscle
weakness
Inaudible (usually) arterial
Doppler signals
Audible venous Doppler signals

Guides to treatment:
Site and extent of occlusion Embolus versus thrombus
Native artery versus bypass graft Duration of ischemia
Patient co-morbidities Contraindications to thrombolysis or surgery

Non-viable limb
(irreversible
ischemia)
Major tissue loss or
permanent nerve
damage inevitable
Profound,
anesthetic sensory
loss
Profound paralysis
(rigor)
Inaudible arterial
Doppler signals
Inaudible venous
Doppler signals

Amputation

Revascularization: Thrombolysis, endovascular, surgical

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Preoperative Cardiac Risk

Each year approximately 50,000 patients

have perioperative MIs, and about 40% of
them will die
Most perioperative MIs occur without the
typical chest pain, due to analgesics after
surgery, residual effects from the
anesthesia, and other perioperative painful
stimuli

Risk Assessment
A. Stepwise Approach:
- Urgency of Surgery
- Clinical Assessment
- Functional Capacity
- Surgical Risk
B. Disease Specific Issues
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular
Evaluation and Care for Non-cardiac Surgery: Circulation

Urgency of Surgery

Urgency:
Emergent
Urgent/soon
Elective

Influences not only risk, but also pre-op testing (if

any) strategy.

Patient-specific Clinical Predictors of Increased

Perioperative Cardiovascular Risk
(ACC/AHA Guidelines)

Major

Acute coronary
syndromes
Decompensated CHF
Significant arrhythmias

Intermediate

Mild angina pectoris

Prior MI

Minor

Advanced age.
Abnormal ECG.
Rhythm other than
sinus.
Low functional
capacity.
History of stroke.
Uncontrolled HTN

Type of Surgery and Risk - I

HIGH SURGICAL RISK:

emergent major operations, esp. in elderly
aortic and other major vascular surgery
peripheral vascular surgery
BIG SURGERY: anticipated prolonged
surgical procedures associated with large fluid
shifts and/or blood loss, and long recovery.

Type of Surgery and Risk - II

Intermediate risk:
carotid
head and neck
intraperitoneal
intrathoracic
orthopedic
prostate

Low risk:
endoscopy
superficial
procedures
cataract surgery
breast surgery

Preoperative Screening

Simple, safe, inexpensive and accurate

Goldman cardiac risk index, Detsky modified
multifactorial risk index and Eagles risk score
Revision of the Goldman risk index by Lee et al.
ischemic heart disease
high-risk surgery
congestive heart failure
cerebrovascular disease
Diabetes-treatment with insulin

Risk
factor

Major cardiac
complication

0.4%

0.9%

7%

11%

renal failure-serum creatinine >2.0 mg/dl

(studied 4315 patients aged 50 years undergoing elective major
noncardiac procedures in a tertiary-care teaching hospital)

Cardiac Evaluation and Care Algorithm for

Noncardiac Surgery
ACC/AHA 2007 Guideline

Need for
emergency
noncardiac
surgery?
no
Active cardiac
conditions*
no
Low risk
surgery
no

ye
s

Operating
room

Unstable coronary
syndromes
ye
Evaluate
and
Decompensated
HF
s
treat per class
(NYHA
functional
ACC/AHA
IV; worsening
or newonset HF)guidelines
Significant arrhythmias
Severe
disease
ye valvular
Proceed
with
s
planned
surgery

Perioperative
surveillance
and postoperative
risk
stratification and
risk factor
management
Consider
operating
room

Noninvasive
Stress
Testing

Cardiac Evaluation and Care Algorithm for

Noncardiac Surgery
ACC/AHA 2007 Guideline
Eating
Functional capacity
Dressing
ye
Proceed with
greater than or
Walking
s
planned
equal to 4 MET
around thesurgery
without symptoms
house
No/unknowDishwashing
n
3 or more
clinical
risk factors
Vascular
surgery
Consider testing if
it will
change
management

1 or 2
clinical
risk factors

ischemic heart
disease
compensated or
prior heart failure
diabetes mellitus
renal
insufficiency
No cerebrovascular
Proceed with
diseaseplanned
clinical

risk
surgery
factors
Intermedia
Intermedia
Vascular
te
te
surgery
risk
risk
surgery
surgery
Proceed with planned surgery with HR
control planned surgery or consider
noninvasive testing if it will change

Pre-Operative Evaluation of
LV function
Resting LV function has
not been shown to be an
independent predictor of
peri-operative ischemic
events.
-Halm EA, Ann Intern Med, 1996
-Rohde LE, Am J Card, 2001
-Kertai MD, Heart 2003

Resting LV Function
<35% does predict postoperative heart failure.
-Kertai MD, Heart 2003

Q. When is revascularization (PCI, CABG)

recommended ? (ACC/AHA Guidelines)
A. Generally only when justified by the usual clinical
factors, apart from planned non-cardiac surgery.

No randomized trials document decreased perioperative

cardiac events.
No prospective studies have determined optimal period of
delay after PCI before noncardiac surgery.
Delay of 2-4 weeks after PCI with stent placement is
supported by observational study.

PROBLEMS WITH PREOP

CORONARY INTERVENTIONS

No proven benefit

May not treat the culprit

Delays surgery versus higher coronary

risk
PTCA : only few days but higher restenosis
risk
Stent : two to six weeks

Coronary Revascularization Does Not

Improve Immediate or Long-Term Outcomes
510 VA pts, aged 66 years, with stable CAD, scheduled for elective
AAA repair (33%) or infrainguinal bypass (67%), randomized to
Revasc (PCI 59%, CABG 41%) or conservative management.

25
20
15
10
5
0

Post-Op MI

30 Day
2.7 Year
Mortality
Mortality
Revascularization Conservative Mgmt
McFalls, E. CARP Trial;AHA 2004

High Risk Patients &

Revascularization Pre-Op
101 pts with extensive ischemia randomly assigned to pre-op revascularization
or not. Endpoints: all-cause death or MI at 30 days and 1-year follow-up.

% mortality

50
40
30
20

2VD in 12 (24%),
3VD in 33 (67%),
Left main in 4 (8%).

10
0
7
14
21
28
Days since surgery

12

Months since surgery

Poldermans, D. JACC 2007; 49(17): 1763

Conclusion

Successful perioperative evaluation and

management of high-risk cardiac patients
undergoing non-cardiac surgery requires careful
teamwork and communication between surgeon,
anesthesiologist, the patients primary caregiver,
and the consultant
Preoperative assessment urgency of noncardiac surgery, patient-specific risk factors, and
surgery-specific considerations needed for
optimal care of patients

Pre-operative
revascularization Guidelines

Pre-operative
revascularization Guidelines

Pre-operative
revascularization Guidelines

Proposed algorithm for patients that

require PCI prior to surgery

Cardiac Evaluation and Care Algorithm for

Noncardiac Surgery
ACC/AHA 2007 Guideline

Need for
emergency
noncardiac
surgery?
no
Active cardiac
conditions*
no
Low risk
surgery
no

ye
s

Operating
room

Unstable coronary
syndromes
ye
Evaluate
and
Decompensated
HF
s
treat per class
(NYHA
functional
ACC/AHA
IV; worsening
or newonset HF)guidelines
Significant arrhythmias
Severe
disease
ye valvular
Proceed
with
s
planned
surgery

Perioperative
surveillance
and postoperative
risk
stratification and
risk factor
management
Consider
operating
room

Noninvasive
Stress
Testing

Cardiac Evaluation and Care Algorithm for

Noncardiac Surgery
ACC/AHA 2007 Guideline
Eating
Functional capacity
Dressing
ye
Proceed with
greater than or
Walking
s
planned
equal to 4 MET
around thesurgery
without symptoms
house
No/unknowDishwashing
n
3 or more
clinical
risk factors
Vascular
surgery
Consider testing if
it will
change
management

ischemic heart
disease
compensated or
prior heart failure
diabetes mellitus
renal
insufficiency
cerebrovascular
disease

No
Proceed with
clinical
planned
risk
surgery
factors
Intermedia
Intermedia
Vascular
te
te
surgery
risk
risk
surgery
surgery
Proceed with planned surgery with HR
control (Class IIa, LOE B) planned surgery
or consider noninvasive testing (Class IIb,
1 or 2
clinical
risk factors

Individuals with PAD Present in Clinical

Practice with Distinct Syndromes
Asymptomatic: Without obvious symptomatic complaint
(but usually with a functional impairment).
Classic Claudication: Lower extremity symptoms
confined to the muscles with a consistent (reproducible)
onset with exercise and relief with rest.
Atypical leg pain: Lower extremity discomfort that is
exertional, but that does not consistently resolve with
rest, consistently limit exercise at a reproducible
distance, or meet all Rose questionnaire criteria.

Individuals with PAD Present in Clinical Practice with

Distinct Syndromes
Critical Limb Ischemia: Ischemic rest pain, nonhealing wound, or gangrene
Acute limb ischemia: The five Ps, defined by the
clinical symptoms and signs that suggest
potential limb jeopardy:
Pain
Pulselessness
Pallor
Paresthesias
Paralysis (& polar, as a sixth p).

Proven Indications for CABG

Significant left main disease

3 V CAD and LV dysfunction

2 V CAD with proximal LAD

involvement

Intractable ischemia

Definition

Acute limb ischemia

is any sudden
decrease or
worsening in limb
perfusion causing a
potential threat to
extremity viability

plaque

Prevalence

PAD affects 12%14% of the general

population and its prevalence increases
with age affecting up to 20% of patients
over the age of 75 (Hiatt et al 1995).
Coexistent coronary artery disease (CAD)
and cerebrovascular disease (CVD) are
highly prevalent in patients with PAD
particularly in the elderly population
patient 68 y.o

Prevalence of PAD increases with

age
San Diego Study (PAD by noninvasive tests)2

Patients with PAD (%)

Rotterdam Study (ABI Test <0.9)1

Figure adapted from Creager M, ed. Management of Peripheral Arterial Disease. Medical, Surgical and Interventional Aspects. 2000.
1 Meijer WT et al. Arterioscler Thromb Vasc Biol 1998; 18: 185-192.
2.Criqui MH et al. Circulation 1985; 71: 510-515.

Levels of Lower Limb Amputation

AboveKnee

Equalanterior&posteriorflaps
Thisiscalledfishmouthincisionbecausewe
havetwoflapstheupperandthelower.
thosearethesamethatsbecausewehave
musclesaroundthefemurfrombackandfront
Toeamputation

BelowKnee

Longposteriorflap
Wedonothave
musclesanteriorly

Symes(heelflap)

mallulicutlevelwithinf.Surfaceoftibia
Midtarsal

Transmetatarsal
(Planterskinflap)

PROGNOSIS
FATE OF PATIENT UNDERGOING BELOW KNEE
AMPUTATION
Earl
After 2
y
years
2nd
healin
g 15%
Above
knee
amputati
on 15 %
Periopera
tive death
10%

1st
healing
60%

Dead 30
%

Full
mobility
40%

Above
knee
amputati Contralat
on 15 % eral
amputatio
n 15 %

Norgren L, Hiatt WR, et al. Inter-Society Consensus for the

Management of Peripheral Arterial

Goldman Preop Cardiac Risk

Index
9 Individual
risk factors
and their
scores are as
follows:

3rd Heart sound (S3)

Elevated JV pressure
MI in past 6 months
ECG: premature atrial contractions
or any rhythm other than sinus

11
11
10
7

ECG shows >5 premature

ventricular contractions per minute

Age >70 years

5
4

Emergency Procedure
Intra-thoracic, intra-abdominal or
aortic surgery

Poor general status, metabolic or

bedridden

Goldman Criteria Results

Patients with scores >25 had a 56% incidence of

death, with a 22% incidence of severe
cardiovascular complications
Patients with scores <26 had a 4% incidence of
death, with a 17% incidence of severe
cardiovascular complications.
Patients with scores <6 had a 0.2% incidence of
death, with a 0.7% incidence of severe
cardiovascular complications.

Detskys
Index
Age
older than 70 years

MI within 6 months

10

MI after 6 mo previously

5
10

Canadian CV society
angina Classification:
Class III
Class IV
Unstable angina in past
6 mo

20
10

Alveolar Pulm Edema: in

past week

10

Alv. Pulm Edema: Ever

Suspected Critical Aortic

Stenosis

20

Arrhythmia: Rhythm other

than sinus or atrial
premature beats

More than 5 premature

ventricular beats

Emergency Operation

10
5

Poor General Medical

Status

Class
I
II
III

Points
0-15
20-30
31+

Risk
LOW
INTM
HIGH

Pre-operative Risk Scoring

1.
2.
3.
4.
5.

ASA
Fit, healthy patient
Mild systemic disease
Severe systemic disease-limiting
activity but not incapacitating
Incapacitating systemic disease-a
constant threat to life
Moribund-not expected to survive

%age of deaths

ASA and Perioperative Mortality

(NCEPOD 2002)

ASA

Lee Cardiac Risk Index

(Lee et al Circulation 1999; 100:1043)

6 Point Score one for each of the following:

High risk surgical procedure
History of IHD
History of CCF
History of Cerebrovasular disease
Insulin-dependent diabetes mellitus
Chronic renal failure (creatinine >177)

Lee Cardiac Risk Index

Validated in 1422 non-cardiac surgical patients

Risk of major cardiac complications

(MI, pulmonary oedema, VF or primary cardiac arrest,

complete heart block)

0 point = 0.4%
1 point = 0.9%
2 points = 7%
3 or more points = 11%

Acute Limb Ischemia (ALI)

I IIa IIb III

Patients with ALI and a salvageable

extremity should undergo an emergent
evaluation that defines the anatomic level
of
occlusion, and that leads to prompt
endovascular or surgical intervention.

I IIa IIb III

Patients with ALI and a non-viable

extremity
should not undergo an evaluation to define
vascular anatomy or efforts to attempt
revascularization.

Acute Limb Ischemia (ALI)

I IIa IIb III

I IIa IIb III

II IIa IIb III

Catheter-based thrombolysis is an
effective and beneficial therapy and is
indicated for patients with acute limb
ischemia (Rutherford categories I and
IIa) of less than 14 days duration.
Mechanical thrombectomy devices can
be used as adjunctive therapy for acute
limb ischemia due to peripheral arterial
occlusion.
Catheter-based thrombolysis or
thrombectomy may be considered for
patients with acute limb ischemia
(Rutherford category IIb) of more than

Revised Cardiac Risk Index

Lee et al. Circ 1999;100:1043.

ROC Curves
Validation Set, n=1422
Goldman (0.70)
Detsky (0.58)
ASA (0.71)
Revised (0.81)

0.5
Specificity

Operative Risk Stratification

Surgical Urgency
emergent
OR

Eagle et al. ACC/AHA Executive Summary. JACC 2002;39:542-53.

Operative Risk Stratification

Surgical Urgency
urgent or elective
OR
no

Prior (<5 years)

revascularization
yes

Recurrent signs/symptoms

yes

no
Further
Risk
Stratification

Operative Risk Stratification

Clinical Predictors
Major

Intermediate

Minor/none

Eagle et al. ACC/AHA Executive Summary. JACC 2002;39:542-53.

Operative Risk Stratification

Clinical Predictors
Major

Intermediate

Minor/none

Postpone Surgery?
Medical Rx and
Risk Factor Optimization

Coronary
Angiography

Operative Risk Stratification

Clinical Predictors
Major

Intermediate

< 4 METs

Minor/none
> 4 METs

Stress Testing

Surgical Procedural Risk

High

Intermediate or Low
OR

Operative Risk Stratification

Clinical Predictors
Major

Intermediate

Minor/none

< 4 METs
Surgical Procedural Risk
Intermediate or Low
OR

> 4 METs

Operative Risk Stratification

Clinical Predictors
Major

Intermediate

Minor/none

< 4 METs
Stress Testing
High

Surgical Procedural Risk

Operative Risk Stratification

Stress Testing Summary
Minor Intermediate Major

Medical Risk

Surgery Specific Risk

Low

OR
Stress test

Intermediate

High

Functional capacity <4 METs: stress test

Optimize RF and/or further eval.

Functional Capacity
Metabolic Equivalents (METs)

Low (< 4 METs)

increased

surgical risk

Intermediate (4-10 METs)

Excellent (> 10 METs)

Functional Capacity
Metabolic Equivalents (METs)

Low (< 4 METs)

increased

surgical risk

IntermediateEating
(4-10 METs)

Dressing
around the house
Excellent (>Walking
10 METs)
Dishwashing

Functional Capacity
Metabolic Equivalents (METs)
Climbing a flight of stairs
Low (< 4 METs)
Level walking at 4 mph
Scrubbing floors
increasedMoving
surgical
riskfurniture
heavy
Golf

Intermediate (4-10 METs)

Excellent (> 10 METs)

Functional Capacity
Metabolic Equivalents (METs)

Low (< 4 METs)

increased

surgical risk
Swimming
(4-10
METs)
Singles
tennis
Basketball

Intermediate

Excellent (> 10 METs)

Peri-operative Therapy
Pre-operative CABG
Some cohort studies suggest lower mortality
after high-risk surgery in post-CABG patients
Eagle et al, Circ 1997 ; CASS database
Patients w/ prior CABG had lower rate of cardiac
death (1.7% vs 3.3, p=.03) after GI, Vascular or
H&N surgery
Hertzer, Ann Surg 1984;199:223

Effect of Prior CABG on Cardiac Risk of

Vascular Surgery: The CASS Registry
10 (n=314)

***
8.5
Periop MI
Death

8
6
4

*
2.8

3.0

***
0.6 1.1

0 No CAD

CAD:
Medical Rx

CAD:
CABG
Eagle et al. Circulation, 1997

Perioperative Cardiac Mortality with

CABG
N=1001

Hertzer, Ann Surg 1984;199:223.

Peri-operative Therapy
Pre-Operative revascularization
-Randomized trials
CARP:
-510 patients, excluded LM disease, severe AS, severe LV
dysfunction (<20%)
258 revascularized (41% CABG, 59% PCI)
225 medically managed
-Deaths at 30 days: 3.1% in revasculazed group, 3.4% in
medically managed group (p=NS)
-Peri-operative cardiac enzyme elevation: 12% vs 14% (p=NS)
-at 2.7 years, mortality was 22%(revascularized) vs 23%
(medical) p=NS.

Peri-operative Therapy
Pre-Operative revascularization, continued
-Randomized trials
DECREASE-V, pre-vascular surgery study
-101 high risk clinical patients (3+ RFs) w/ extensive
ischemia on stress testing
-52 medically treated
-49 revascularization (65% PCI, 35% CABG)
-94% of the PCIs were with DES
-Vascular surgery: median 29 days after CABG, 31 days
after PCI
-30 day mortality and MI: 43% (revascularized) vs 33%
(medical), p=0.30
-1 year mortality and MI: 49% vs 44%, p=0.48

Perioperative Cardiac Events

with PTCA
% Death and Nonfatal MI

Vascular Patients

Khot UN, Ellis SG. ACC Current J Rev 2001;10:57.