Krupski W C, Layug E L, Reilly L M, Rapp J H, Mangano D T
Section of Vascular Surgery, Department of Veterans Affairs Medical Center, San Francisco.
J Vasc Surg. 1992 Feb;15(2):354-63; discussion 364-5.
We prospectively compared the differences in perioperative cardiac ischemic events in 140 patients undergoing major abdominal (n = 53) versus infrainguinal (n = 87) vascular operations. Preoperative dipyridamole thallium cardiac scintigraphy was performed in a subset of 38 of these patients, with treating physicians blinded to the test results. Myocardial ischemia was measured during operation with use of continuous 12-lead electrocardiography (ECG) and transesophageal echocardiography. Continuous two-lead ambulatory ECG (Holter monitoring) was performed before, during, and after operation for 4 days. Outcome events were cardiac death, nonfatal myocardial infarction, unstable angina, ventricular tachycardia, and congestive heart failure. Results of the study indicated that most demographic variables, such as age, hypertension, cigarette smoking, serum cholesterol, were comparable between patients having aortic or infrainguinal arterial operations. However, in the infrainguinal group more patients had diabetes, second vascular operations, angina pectoris, heart failure, dysrhythmias, and used digitalis. Abnormalities in preoperative Holter monitoring, ECGs, and thallium scan abnormalities were equivalent between groups. During operation, whereas Holter and ECG abnormalities were comparable, more patients undergoing aortic procedures suffered ischemia as determined by transesophageal echocardiography (26% vs 10%, p = 0.019). After operation there were 21 (24%) outcome events in patients having infrainguinal bypasses compared with 15 (28%) patients having aortic procedures (p = NS). Ischemia by Holter monitoring (n = 133) occurred after operation in 46 (57%) patients having infrainguinal operations compared with 16 (31%) patients having aortic reconstructions (p = 0.005). Because preoperative cardiac disease and adverse cardiac outcomes occurred with similar or even greater frequency in both groups of patients, we conclude that the risk for postoperative cardiac ischemic events in lower extremity vascular operations is at least as great as for aortic operations.
我们前瞻性地比较了140例行腹部大手术（n = 53）与腹股沟下血管手术（n = 87）患者围手术期心脏缺血事件的差异。对其中38例患者进行了术前双嘧达莫铊心肌闪烁扫描，主治医生对检查结果不知情。术中使用连续12导联心电图（ECG）和经食管超声心动图测量心肌缺血情况。术前、术中和术后4天进行连续双导联动态心电图（Holter监测）。结局事件包括心源性死亡、非致命性心肌梗死、不稳定型心绞痛、室性心动过速和充血性心力衰竭。研究结果表明，大多数人口统计学变量，如年龄、高血压、吸烟、血清胆固醇，在接受主动脉或腹股沟下动脉手术的患者之间具有可比性。然而，腹股沟下组更多患者患有糖尿病、再次血管手术史、心绞痛、心力衰竭、心律失常，并使用洋地黄。术前Holter监测、心电图及铊扫描异常在两组间相当。术中，虽然Holter和心电图异常情况相当，但经食管超声心动图显示，接受主动脉手术的患者中更多出现缺血（26% 对10%，p = 0.019）。术后，行腹股沟下旁路手术的患者中有21例（24%）发生结局事件，而行主动脉手术的患者中有15例（28%）发生结局事件（p = 无显著性差异）。腹股沟下手术患者术后通过Holter监测发现缺血的有46例（57%）（n = 133），而行主动脉重建术的患者中有16例（31%）（p = 0.005）。由于两组患者术前心脏疾病及不良心脏结局的发生率相似甚至更高，我们得出结论，下肢血管手术术后心脏缺血事件的风险至少与主动脉手术一样大。
