Multifocal arterial disease – surgical strategies

M. Dumitrașcu, Raluca Dantis, L. Stan – Central Military Hospital, Bucharest

Ateroscleroza este o boală sistemică care afectează mai multe organe și sisteme. Leziunea care trebuie tratată mai întâi este cea care prezintă cele mai multe simptome sau leziunea cu cel mai puternic impact prognostic. Boala coronariană poate coexista cu stenoza arterei carotide, anevrismele de aortă abdominală și/sau boala arterială periferică (BAP).

Studii recente au confirmat faptul că pacienții cu boală multivasculară au un risc mai mare de evenimente cardiovasculare majore decât pacienții cu afectare monovasculară.
Leziunile vasculare trebuie tratate astfel: leziuni carotidiene, leziunile coronariene și leziunile aortice sau periferice. Când două teritorii arteriale sunt simptomatice (ex: AAA mai mare de 7 cm în diametru sau în iminența rupturii, asociat cu boala coronariană stângă) putem efectua proceduri simultane (deschise sau endovasculare), dar cu o rată a mortalității semnificativ mai mare.

Atherosclerosis is a global disease affecting multiple organs. The symptomatic lesion or the lesion with the strongest prognostic impact should be treated first.
Coronary artery disease may coexist with carotid artery stenosis, abdominal aortic aneurysms, and/or peripheral artery disease (PAD).

Recent studies have confirmed that patients with multivascular bed disease have a greater risk for major cardiovascular events than patients with monovascular attempt.
The lesions should be treated as follows: carotid, coronaries and aorta or peripheral lesions. When two arterial beds are symptomatic (ex: AAA more than 7cm in diam. or in imminence of rupture associated with left main disease) we can perform simultaneous procedures (open or endovascular), but with higher mortality rate (25%).

• Vascular patients often have concomitant arterial disease affecting more than one territory.
• Identification of silent vascular disease is essential to improve cardiovascular mortality and morbidity rates.
• The treatment of multifocal arterial disease should include aggressive risk factor management, lifestyle changes, and appropriate drug therapy.

In patients with multifocal arterial disease, myocardial revascularization is indicated before the vascular intervention, with the exception of carotid lesions.
In these polivascular patients, cardiac complications are:

• in aortic surgery = 4% – 8%
• in carotid surgery = 2%

To avoid the unnecessary coronarographies, it is mandatory to identify the predictive clinical parametres for myocardical revascularization (surgical or interventional).
The surgical treatment of panvascular disease puts today difficult therapeutic strategies and often controversial.
Today’s treatment:
CABG before aorto-iliac revascularization with a waiting interval of 1-2 months.
Prof. Kieffer, Prof. Coriat (Pitie Salpetriere Hospital of Paris),in a study published in 1999 on 270 patients operated of terminal aortic pathology and 250 patients of carotid pathology.

They have identified the following factors:

• Age > 64 years old;
• The existence of coronary insufficiency with clinical manifestations (chest pain or myocardical infarction history);
• The presence of abdominal aorta aneurysm (versus occlusive pathology).

For a simultaneous surgery (CABG + terminal Aorta surgery), a rigorous selection of the patients must be made:

• young age
• good general status
• no obesity
• no COPD

In our clinic, in 2003 on one year period, on 400 direct arterial revascularisations we had 11 patients with multiple sites of atherosclerotic disease. The decade more affected was 60 – 70 years old. After 20 years, in 2023, the number of patients increases a lot, at 120, and the patients were older. (decade 70-80 y). Man were more affected.

Conclusions:

• The treatment must be personalized, decided by a multidisciplinary team
• Priority: the most symptomatic lesion or the one with the strongest impact
• It is unanimously accepted the therapeutic strategy:
• carotid – coronary – peripheral
• Panvascular disease = complex management.

In PVD patients, the prevalence of the coronary insufficiency is at least 40% – 50%, while myocardial revascularization is between 10% and 25%.
The prevalence of the carotid artery stenosis is 10,5%.
Coronary lesions and/or carotid artery lesions, even when treated, represent a significant risk factor of post-surgical death. It needs a systematic pre-operative screening.

Selected Bibliography:

1. Desormais, Ileana; Vlachopoulos, Ch.; Aboyans, V.; Panvascular Disease – Epidemiology and prevention, Cor et vasa 60, 2018 e3-e8, Elsevier ed.;
2. Aboyans, V.; Ricco, J.B.; Bartelink, M.E.L. et al.; 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial disease, in collaboration with ESVS;
3. Adiarto, S.; Nurachman, L.A.; Dewangga, R.; Indriani, S.; Taofan, T.; Alkatiri, A.A.; Firman, D.; Santoso, A.; Predicting multivascular disease in patients with coronary artery disease; F1000 Research 2023, 12:750;
4. Naka, Katerina K.; Aboyans, V.; Vlachopoulos, Ch.; Panvascular Disease – Diagnosis and management, Cor et vasa 60, 2018, e9-e17, Elsevier ed.;
5. Paraskevas, K.I.; Geroulakos, G.; Veith F.J.; Mikhailidis, D.P.; Multifocal arterial disease: clinical implications and management; Current Opinion, 2020, vol. 35 no. 4, pg. 412-416;
6. Achim, A.; Peter, O.A.; Cocoi, M.; Serban, Adela.; Mot, S.; Dadarlat-Pop, Alexandra.; Nemes, A.; Ruzsa, Z.; Correlation between Coronary Artery Disease with other Arterial Systems: Similar, Albeit Separate, Underlaying Pathophysiologic Mechanisms; J. Cardiovasc. Dev. Dis. 2023, 10, 210; pg. 1-13.