Clinical Question: In patients with significant, stable coronary disease, is coronary artery revascularization helpful before major vascular surgery?

Setting: Inpatient (any location) with outpatient follow-up

Study Design: Randomized controlled trial (nonblinded)

Allocation: Concealed

Synopsis: Patients undergoing repair of an expanding abdominal aortic aneurysm (AAA) or peripheral vascular surgery underwent angiography if they were at high risk for cardiovascular complications on the basis of standard guidelines. If one or more coronary arteries had a 70 percent stenosis, the patient was randomized to receive revascularization (59 percent had angioplasty, 41 percent had a coronary artery bypass graft) or no revascularization. Of 5,859 patients initially enrolled, 1,654 were not at high risk, 1,025 required urgent surgery, 626 had previous revascularization, 731 had a severe coexisting illness, 633 were already in another study or declined to participate, and 680 were excluded for various other reasons. That left 510 patients for randomization; the groups were balanced at the start of the study.

Patients were followed for up to six years (mean follow-up time = 2.8 years). There were more deaths before surgery in the revascularization group (10 versus one), no difference in deaths in the 30 days after the peripheral vascular surgery or AAA repair (seven versus eight), and no difference in long-term all-cause mortality (22 versus 23 percent). The outcomes were the same for intention-to-treat and per-protocol analyses.

Bottom Line: Patients with significant, stable coronary artery disease do not benefit from revascularization before major peripheral vascular surgery. (Level of Evidence: 1b)