Commentary: Global Management of Concomitant Peripheral Vascular and Coronary Diseases: The Role of the Invasive Cardiologist

The study by Rigatelli et al illustrates the global nature of atherosclerotic disease, an established fact well known to the endovascular specialist. However, routine visualization of the peripheral vasculature during coronary angiography without pre-specified and well-established indications could lead to unnecessary, expensive and risky therapies. For instance, there is no proven benefit of percutaneous treatment of renal artery stenosis in patients without a history of severe uncontrolled hypertension on multiple drug therapy, worsening renal insufficiency or intractable angina and congestive heart failure. Therefore, “drive-by shooting” the renals without these pre-specified endpoints should be discouraged.

The same applies to the subclavian or lower extremity vasculature. In a recent study presented by our group at the International College of Angiology (Lexington, Kentucky, 2004), we have evaluated the frequency of left internal mammary artery (LIMA) significant disease (>50%) prior to bypass surgery and described associated significant lateral costal branches (>1.5 mm), and severe subclavian disease (>50%). The findings were correlated with the persistence of anterior wall ischemia on cardiolite testing post surgery. In 101 consecutive patients, none of the patients had a LIMA with disease > 50%. Only one patient had a narrowing between 25-50%. Significant proximal subclavian disease (>50%) occurred in 6.3% of the cases. Cardiolite stress imaging post bypass showed that persistent ischemia in the LAD territory post CABG did not correlate with the presence of large costal branches or subclavian disease.

Despite current controversy about routine LIMA visualization prior to bypass surgery, we have currently reserved LIMA and subclavian visualization to patients with significant differences in their systolic blood pressure between both arms (>20 mmHg) or symptomatic subclavian narrowing. Finally, routine visualization of the lower extremity vasculature with no significant symptoms (Rutherford-Baker Classification I and II) is not known to alter the natural history of the disease or the lifestyle of the patient. Therefore, angiography to the lower extremity and revascularization needs to be reserved for symptomatic patients whose lifestyle is impaired because of the disease or for limb ischemia patients. The global management of the patient with diffuse atherosclerosis should always be done on a background of aggressive preventative measures. These include supervised and regular exercise, statin therapy, antiplatelet drugs, avoiding smoking, and an aggressive management of diabetes and hypertension. It should be noted that most of these patients do not die of their peripheral vascular disease. Over 75% of death in these patients is cardiac in origin. Therefore, preventative measures are of utmost importance to these patients and aggressive endovascular therapy should be reserved to those who meet clear proven indications.