Tag Archives: JAMA

Comment on “Incidence of Myocardial Infarction After High-Risk Vascular Operations in Adults” by Yen-Yi Juo et al. JAMA Surg. 2017

Question raised by the paper – MI incidence in high risk vascular surgery didn’t decrease despite advanced cardiac care pre-op (2.7% 30 day MI in 2009; 3.1% in 2014).
My comment on this paper – This study only analyzed high risk procedure includes open AAA and infrainguinal bypass. Endovascular intervention was not included so SHOULD NOT BE MENTIONED ANYWHERE IN THE ARTICLE.
This study has poor generalizability. It is retrospective study on a very unspecific database. NSQIP database lacks specifics on location of cross-clamping in aortic cases and detailed perioperative medical management. Study population is predominantly white, and criteria for MI was not specified and only included up to 30 days.
With the advancement of endovascular intervention, more AAA and TAAA are treated with simple or complex EVAR (branched or fenestrated). The more emergency procedure in open AAA cohort reflects the makeup of open procedure for AAAs, as more and more elective cases of AAA are done endovascular. Open aortic procedure are also becoming increasingly complex, as the simple AAAs with adequate infrarenal aneurysm neck size, length, morphology are treated predominantly by EVAR. The leftover ones with aneurysm neck angulation and large diameter, juxtarenal/pararenal AAA, etc comprise the open AAA intervention. Thus, one can extrapolate that the open AAA procedures are becoming higher risk with expected poorer outcomes. It is no surprise that there is significantly higher actual incidence of post-op MI in open AAA repair [3.0%] vs [1.9%] in infrainguinal bypass, which is more of an elective procedure with subacute patient presentation. Therefore, pre-op cardiac workup and optimization are paramount. However, one cannot associate endovascular intervention with poorer outcome. EVAR, if anything, has made repair of AAA and TAAA into a low risk procedure, without the need for general anesthesia or cross clamp, and made even the rupture of AAA a controllable incident. It has made the cases of AAA/TAAA that require open approach more morbid procedure, but broad perspective that include all AAA/TAAA treated open and endovascularly would likely reflect an improvement in long term outcome of these patients.