Pauls Stradins Clinical University Hospital, Riga, Latvia; University of Latvia, Riga, Latvia.
Pauls Stradins Clinical University Hospital, Riga, Latvia; University of Latvia, Riga, Latvia.
Eur J Vasc Endovasc Surg. 2020 Sep;60(3):411-420. doi: 10.1016/j.ejvs.2020.05.027. Epub 2020 Jul 22.
Patients undergoing peripheral vascular surgery have increased risk of death and myocardial infarction (MI), which may be due to unsuspected (silent) coronary ischaemia. The aim was to determine whether pre-operative diagnosis of silent ischaemia using coronary computed tomography (CT) derived fractional flow reserve (FFR) can facilitate multidisciplinary care to reduce post-operative death and MI, and improve survival.
This was a single centre prospective study with historic controls. Patients with no cardiac symptoms undergoing lower extremity surgical revascularisation with pre-operative coronary CTA-FFR testing were compared with historic controls with standard pre-operative testing. Silent coronary ischaemia was defined as FFR ≤ 0.80 distal to coronary stenosis with FFR ≤ 0.75 indicating severe ischaemia. End points included cardiovascular (CV) death, MI, and all cause death through one year follow up.
There were no statistically significant differences between CT angiography (CTA-FFR (n = 135) and control (n = 135) patients with regard to age (66 ± 8 years), sex, comorbidities, or surgery performed. Coronary CTA showed ≥ 50% stenosis in 70% of patients with left main stenosis in 7%. FFR revealed silent coronary ischaemia in 68% of patients with severe ischaemia in 53%. The status of coronary ischaemia was unknown in the controls. At 30 days, CV death and MI in the CTA-FFR group were not statistically significantly different from controls (0% vs. 3.7% [p = .060] and 0.7% vs. 5.2% [p = .066], respectively). Post-operative coronary revascularisation was performed in 54 patients to relieve silent ischaemia (percutaneous coronary intervention in 47, coronary artery bypass graft in seven). At one year, CTA-FFR patients had fewer CV deaths (0.7% vs. 5.9%; p = .036) and MIs (2.2% vs. 8.1%; p = .028) and improved survival (p = .018) compared with controls.
Pre-operative diagnosis of silent coronary ischaemia in patients undergoing lower extremity revascularisation surgery can facilitate multidisciplinary patient care with selective post-operative coronary revascularisation. This strategy reduced post-operative death and MI and improved one year survival compared with standard care.
接受外周血管手术的患者死亡和心肌梗死（MI）的风险增加，这可能是由于未被发现的（无症状的）冠状动脉缺血所致。本研究旨在确定使用冠状动脉计算机断层扫描（CT）衍生的血流储备分数（FFR）术前诊断无症状性缺血是否能促进多学科治疗，以降低术后死亡和 MI 发生率，并改善患者的生存率。
这是一项单中心前瞻性研究，设有历史对照。对接受下肢血管重建术但术前接受冠状动脉 CT-FFR 检查的患者与术前接受标准检查的历史对照患者进行比较。无症状性冠状动脉缺血定义为冠状动脉狭窄远端 FFR≤0.80，FFR≤0.75 表示严重缺血。主要终点包括心血管（CV）死亡、MI 和术后 1 年全因死亡。
在年龄（66±8 岁）、性别、合并症或手术类型方面，CT 血管造影（CTA-FFR（n=135）和对照组（n=135）之间无统计学差异。70%的患者冠状动脉 CTA 显示≥50%狭窄，7%的患者左主干狭窄。FFR 显示 68%的患者存在无症状性冠状动脉缺血，其中 53%的患者存在严重缺血。对照组中冠状动脉缺血状态未知。在 30 天时，CTA-FFR 组的 CV 死亡和 MI 发生率与对照组无统计学差异（0% vs. 3.7%[p=0.060]和 0.7% vs. 5.2%[p=0.066]）。54 例患者因无症状性缺血行术后冠状动脉血运重建（经皮冠状动脉介入治疗 47 例，冠状动脉旁路移植术 7 例）。1 年后，CTA-FFR 组 CV 死亡（0.7% vs. 5.9%；p=0.036）和 MI（2.2% vs. 8.1%；p=0.028）发生率较低，生存率较高（p=0.018）。
在接受下肢血管重建手术的患者中，术前诊断无症状性冠状动脉缺血可促进多学科患者管理，选择性进行术后冠状动脉血运重建。与标准治疗相比，该策略降低了术后死亡率、MI 发生率和 1 年生存率。
