New treatment possibilities for patients with advanced coronary artery disease and critical limb ischemia – a feasibility study

Atherosclerosis can be limited to one vascular bed, but more often it takes a diffused form. Detection of the disease in one area should prompt further assessment of the patient for atherosclerotic disease in different territories. According to various studies, in patients over 50 years old with peripheral artery disease (PAD), critical limb ischemia (CLI) affects 1–2% of this population. These patients have very high risk of cardiovascular events due to concomitant coronary and cerebrovascu-lar disease (5-year event rate of 20%), and it has been proven that those events occur more frequently than ischemic events of the lower extremities, regardless of the stage of the lower extremity arterial disease (LEAD). Furthermore, over the 5-year observation period, 75% of deaths are caused precisely by cardiovascular events [1]. Prevalence of coronary and carotid artery disease in patients with LEAD, as reported by various studies, is between 50% and 60%. In the authors' registry of 218 patients with peripheral artery disease undergoing diagnostic coronary angiography, significant co-existing coronary artery disease was diagnosed in patients with LEAD or carotid artery disease in 63% and 65% respectively. It is interesting that 72% of those patients had never had any coronary artery disease (CAD) symptoms. Detection of concomitant CAD in patients with LEAD is especially important before planning the surgical strategy. Peripheral vascular surgery is considered a high-risk surgery, with the highest risk of cardiac complications (estimated 30-day cardiac event rates – cardiac death and myocardial infarction (MI) – of over 5%) [2–9]. According to the above data, detailed cardiac evaluation of patients with LEAD undergoing vascular surgery should be performed routinely and become a standard of care. Patients with CLI have worse prognoses than patients with different forms of malignant diseases and, as yet, no way has been found to improve these prognoses. Overall, mortality in patients with CLI approaches 50% at 5 years and 70% at 10 years [1]. Because of that, in our facility diagnostic peripheral angiography in patients with CLI is followed by routine coronary angiography. Our planned strategy for patients with CLI requiring immediate vascular surgery and diagnosed with advanced coronary artery disease (critical narrowing of main coronary artery) was hybrid treatment. The benefit of one-stage treatment is diminishing the risk of peripro-cedural cardiac complications in patients with peripheral arterial disease. The negative aspect of this approach is the high risk of early stent thrombosis during the vascular surgery, which activates …