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Coronary-Artery Revascularization before elective vascular surgery does not significantly alter the long-term outcome

December 30, 2004

Minneapolis, MN -- In a multicenter, randomized trial, 510 patients were assigned to either coronary-artery revascularization before vascular surgery or no revascularization before surgery. The principal finding of this study, published by Edward O. Mcfalls, M.D., PhD et. al. from the Minneapolis Veterans Affairs Medical Center in Minneapolis, Minnesota, in the December 30, 2004 issue of the New England Journal of Medicine is, that among patients with stable coronary artery disease, coronary-artery revascularization before elective major vascular surgery does not improve long-term survival.  

The benefit of coronary-artery revascularization prior to elective major vascular surgery has been previously unclear. Therefore, the Coronary Artery Revascularization Prophylaxis (CARP) trial assessed the long-term benefit of preoperative coronary-artery revascularization among patients with stable coronary artery disease who are scheduled for elective vascular surgery. The primary endpoint was long-term mortality. The secondary end-point included myocardial infarction, stroke, limb loss, and dialysis.  

Of 5859 patients scheduled for vascular operations at 18 Veterans Affairs (VA) centers, 510 (9 percent) were eligible for the study. Of this group, 258 were assigned to a strategy of preoperative coronary-artery revascularization, and 252 to no revascularization. The indications for a vascular operation were an expanding abdominal aneurysm or arterial occlusive disease of the legs. Among the patients assigned to preoperative coronary-artery revascularization, percutaneous coronary intervention was performed in 59 percent, and bypass surgery was performed in 41 percent. At 2.7 years after randomization, mortality in the revascularization group was 22 percent and in the no-revascularization group 23 percent (relative risk, 0.98; 95 percent confidence interval, 0.7 to 1.37; P=0.92). Within 30 days after the vascular operation, a postoperative myocardial infarction, defined by elevated troponin levels, occurred in 12 percent of the revascularization group and 14 percent of the no-revascularization group (P=0.37) 

In conclusion, the CARP trial shows that coronary-artery revascularization before elective vascular surgery does not alter long-term survival. Although the study did not include the short-term effects of the revascularization, there also seems to be no reduction in the number of post-operative myocardial infarctions, deaths or days in the hospital. The findings support the opinions of the task force of the American College of Cardiology, the American Heart Association and the American College of Physicians, which have recommended that CABG or percutaneous coronary interventions be reserved for patients with unstable cardiac symptoms or advanced coronary artery disease, for whom a survival benefit with CABG has been proven. From this data, it can be concluded that coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended.  

Co-authors: Herbert B. Ward, M.D., Ph.D., Thomas E. Moritz, M.S., Steven Goldman, M.D., William C. Krupski, M.D., Fred Littooy, M.D., Gordon Pierpont, M.D., Steve Santilli, M.D., Joseph Rapp, M.D., Brack Hattler, M.D., Kendrick Shunk, M.D., Ph.D., Connie Jaenicke, R.N., B.S.N., Lizy Thottapurathu, M.S., Nancy Ellis, M.S., Domenic J. Reda, Ph.D., and William G. Henderson, Ph.D.

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