Major vascular surgery and angina

49-year-old lady for complete endovascular reconstruction of Aortic bifurcation, endoluminal graft, and reconstruction of aorto-iliac segment.


  • Significant peripheral vascular disease – intermittent claudication, limiting all exercise.
  • Wheelchair bound outside home
  • Morbid obesity
  • NIDDM. HbA1c = 5.8%


  • Recurrent episodes of angina on minimal exertion over the last 3 months
  • Exercise stress echocardiogram performed – submaximal test due to leg pain. Exercised 3-4 METs and reached 69% of predicted heart rate
  • Chest pain during test, normal ECG and no exercise-induced Regional Wall Motion Abnormalities or reduction in end-systolic volumes
  • CTCA recommended by treating cardiologist
  • CTCA – Left main disease. ‘Extensive CAD with at least 50-69% stenosis in left main and mid RCA.’ Calcium score 439 (above 95th percentile)
  • Discussed at cardiology meeting. Plan to postpone and perform coronary angiogram



  • Discussion as to the value of the test in this patient
  • Young patient but high calcium score not unexpected given existing vascular disease
  • Coronary CTA VISION study – evaluated role of CTCA in perioperative risk stratification.
  • Results showed patients were x 5 times more likely to have an inappropriate over-estimation of surgical risk based on RCRI after coronary CTA
  • Coronary angiogram likely to be a better test in this patient

LM disease

  • CABG vs PCI discussed
  • Traditionally, left main disease was an indication for CABG
  • Extensive area of myocardium involved with increased potential for morbidity and mortality
  • Evolution of practice, newer generation of DES, and improved adjuvant drug therapy has created better outcomes for PCI in LMCA
  • 2 recent RCT’s EXCEL and NOBLE compared revascularization with PCI to surgical techniques with conflicting results.
  • Both trials showed similar long‐term survival rates to CABG surgery, particularly in those with low and intermediate anatomic risk. 
  • However, patients undergoing PCI had higher need for repeat revascularization in the future.
  • Which patients are suitable for PCI? Current guidelines from AHA state they ‘strongly recommend surgical revascularization for LMCAD (class IA) with PCI considered a reasonable alternative (class II) in select patients with less complex anatomy and clinical characteristics that predict an increased risk of adverse surgical outcomes.’


  • Discussed at cardiology meeting – to proceed to coronary angiogram
  • Patient and surgeon aware of plan.