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Peripheral Vascular Disease and Intervention
Pre-Op Diagnosis of Lesion-Specific Ischemia Using CT-Derived Fractional Flow Reserve (FFRCT) May Reduce Post-Op MI and Death in Patients Undergoing Peripheral Vascular Surgery
Dainis Krievins1, Edgars Zellans1, Karlis Kaufmanis2, Gustavs Latkovskis1, Indulis Kumsars1, Roberts Rumba1, Ligita Zvaigzne1, Andrejs Erglis1, Christopher K. Zarins3
Pauls Stradins Clinical University Hospital, Latvia1, Pauls Stradins clinical university hospital, Latvia2, HeartFlow Ltd., USA3
Peripheral vascular surgery (PVS) patients have increased risk of post-op MI/death which may be due to unrecognized coronary ischemia. Coronary CT-derived fractional flow reserve (FFRCT) can identify lesion-specific ischemia in stable chest pain patients but its value in PVS is unknown. We sought to determine if pre-op FFRCT can reduce post-op cardiac events in PVS patients.
PVS patients with no cardiac symptoms had pre-op CT-FFRCT in a prospective, IRB - approved Study and were compared to matched retrospective Controls who had PVS with standard pre-op testing. Lesion-specific ischemia was defined as FFRCT   0.80 distal to stenosis. Primary endpoint was major adverse cardiac event (MACE = cardiac death, MI or urgent revascularization) at 30 days and 12 months. 
Study (n = 135) and Control (n = 135) patients were similar in age (65 8 vs 66 8 years), gender (80 % v 82 % male), risk factors, pre-op ABI and surgery performed. CTA in Study showed extensive calcification (Agatston 1156 1026) with left main in 7 % and  50 % stenosis in 70 %. Silent ischemia was present in 86/126 (68 %) Study patients; 56 % had multivessel ischemia. PVS was performed in all Controls and 130 (96 %) Study patients (5 were postponed: 1 PCI, 4 medical).  No post-op deaths in Study 0 vs 5 due to MI in Control; one Study patient had post-op MI on day 3 with successful emergent PCI.  MACE at 30 days in Study was 1/135 (0.7 %) vs 7/135 (5.2 %) in Control (p = 0.06). Elective coronary angiography was performed in 75 Study patients with left main, severe or multivessel ischemia 1-3 months post-op with coronary revascularization in 54 (47 stents; 7 CABG).  At 12 months follow up, compared to ControlsStudy patients had significant reduction in cardiac death (0 vs 4.4 %, p = 0.007), MI (2.2 vs 8.1 %, p = 0.028) and MACE (2.2 vs 8.1 %, p = 0.028). 
Asymptomatic lesion-specific ischemia is present in 2 of 3 patients undergoing peripheral vascular surgery. Pre-op CT-FFRCT diagnosis can help guide multi-disciplinary team approach to reduce post-op death/MI. Favorable results of staged peripheral and coronary revascularization at one year suggest the need for further controlled outcome studies.  
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