Vascular surgery patients are knowingly at increased risk for perioperative cardiovascular complications. Perioperative myocardial injury (POMI) has been found to be a significant contributor to perioperative short- and longterm mortality after non-cardiac surgery [1]. It has been demonstrated that perioperative myocardial injury can occurr in about 24% of vascular surgery patients and is associated with increased 1-year-mortality [2]. The aim of the present study was to assess risk factors for the development of POMI in patients undergoing different types of vascular surgical procedures.

This was a retrospective single-center analysis including all adult patients undergoing vascular surgery, with the exception of varicose vein operations and surgical wound debridement, between January 2016 and June 2017. Only patients with complete data sets were included. POMI was defined according to the current guidelines of the German Society of Cardiology which are based on Thygesen et al. [3]. Accordingly, a postoperative troponin rise or fall with >20% variation from baseline value was considered a POMI. The incidence of POMI was evaluated in the overall patient cohort as well as separately by operation type (major amputation, peripheral arterial surgery, surgery of the supraaortic branches, aortic surgery) and a uni- and multivariate risk factor analysis including different demographic and perioperative factors was performed.

383 patients (65 male, mean age 73 ± 11 years) were included and POMI was diagnosed in 103 of them. The overall univariate analysis of all types of operation showed a significant association of age (p=0,03), emergency surgery (OR 3,2; p<0,0001), low intraoperative hemoglobine (OR 0,86; p=0,02), necessity of blood transfusion (OR 2,35; p=0,003) and operating time (p= 0,02) with POMI. Typical arteriosclerosis risk factors such as arterial hypertension (OR 1,2; p=0,61) and insuline-dependent diabetes (OR 1,3;p=0,41) were not predictive of POMI in the present analysis. However, the risk of POMI was significantly increased in patients with a history of cardiac intervention/surgery (OR 1,59, p=0,05). Patients, in whom coronary artery disease (CAD) was diagnosed for the first time during preoperative cardiological work-up, had a significantly reduced risk of POMI in the multivariate analysis (OR 0,37; p=0,01). Regarding the different types of operation, POMI occurred in about a third of patients with aortic surgery (34/97) and about a fourth of patients with peripheral arterial surgery (44/176). Especially in aortic and peripheral arterial operations, emergency surgery was found to be a significant predictor of POMI. Finally, female sex was a significant predictor for POMI in patients undergoing aortic surgery (OR 2,9; p=0,03).

This study confirms that patients undergoing vascular surgical procedures are at high risk of POMI. Since emergency surgery was the main predictor of POMI in the present analysis, this additional risk should be born in mind when making the decision to operate emergently. Especially female patients undergoing aortic surgery are at high risk of POMI, so that preoperative cardiological consultation should be considered mandatory in this patient group. Since the prevalence of POMI was signficiantly higher in patients with a history of cardiac intervention/surgery, a preoperative cardiological consultation should also be recommended to patients who had a coronary intervention/surgery in the past, especially prior to aortic or peripheral vascular surgery, in order to reduce the POMI risk. Finally, further studies to evaluate the effect of POMI on (longterm) clinical outcomes of vascular surgery patients are required.

[1] Puelacher C, Lurati Buse G, Seeberger D, Sazgary L, Marbot S, Lampart A, Espinola J, Kindler C et al.; BASEL-PMI Investigators. Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization. Circulation. 2018 Mar 20;137(12):1221-1232. doi: 10.1161/CIRCULATIONAHA.117.030114. Epub 2017 Dec 4. PMID: 29203498. [2] Górka J, Polok K, Fronczek J, Górka K, Kózka M, Iwaszczuk P, Frołow M, Devereaux PJ et al. Myocardial Injury is More Common than Deep Venous Thrombosis after Vascular Surgery and is Associated with a High One Year Mortality Risk. Eur J Vasc Endovasc Surg. 2018 Aug;56(2):264-270. doi: 10.1016/j.ejvs.2018.02.005. Epub 2018 Mar 23. PMID: 29580830. [3] Kristian Thygesen, Joseph S Alpert, Allan S Jaffe, Bernard R Chaitman, Jeroen J Bax, David A Morrow, Harvey D White, ESC Scientific Document Group, Fourth universal definition of myocardial infarction (2018), European Heart Journal, Volume 40, Issue 3, 14 January 2019, Pages 237-269, https://doi.org/10.1093/eurheartj/ehy462