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CARDIOVASCULAR ANESTHESIA

Perioperative- and Long-Term Mortality Rates After Major Vascular Surgery: The Relationship to Preoperative Testing in the Medicare Population

Lee A. Fleisher, MD^*,,, Kim A. Eagle, MD^§, Thomas Shaffer, MHS, and Gerard F. Anderson, PhD^,

Departments of *Anesthesiology, Medicine, and Health Policy and Management, Johns Hopkins Medical Institutions, Baltimore, Maryland; and §Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan

Address correspondence and reprint requests to Lee A. Fleisher, MD, The Johns Hopkins Hospital, 600 North Wolfe St., Carnegie 280, Baltimore, MD 21287. Address e-mail to lfleishe{at}welchlink.welch.jhu.edu

Debate continues regarding the value of cardiovascular testing and coronary revascularization before major vascular surgery. Whereas recent guidelines have advocated selective preoperative testing, several authors have suggested that it is no longer necessary in an era of low perioperative cardiac morbidity and mortality. We used data from a random sample of Medicare beneficiaries to determine the mortality rate after vascular surgery, based on the use of preoperative cardiac testing. A 5% nationally random sample of the aged Medicare population for the final 6 mo of 1991 and first 11 mo of 1992 was used to identify a cohort of patients who underwent elective infrainguinal or abdominal aortic reconstructive surgery. Use within the first 6 mo of 1991 was reviewed to determine if preoperative noninvasive cardiovascular imaging or coronary revascularization was performed. Thirty-day (perioperative) and 1-yr mortalities were assessed. Perioperative mortality was significantly increased for aortic surgery (209 of 2865 or 7.3%), compared with infrainguinal surgery (232 of 4030 or 5.8%); however, 1-yr mortality was significantly increased for infrainguinal surgery (16.3% vs 11.3%, P < 0.05). Stress testing, with or without coronary revascularization, was associated with improved short- and long-term survival in aortic surgery. The use of stress testing with coronary revascularization was not associated with reduced perioperative mortality after infrainguinal surgery. Stress testing alone was associated with reduced long-term mortality in patients undergoing infrainguinal revascularization.

Implications: Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality. The reduced long-term mortality in patients who had previously undergone preoperative testing and coronary revascularization reinforces the need for a prospective evaluation of these practices.

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