Amounts of Coronary Arterial Narrowing by Atherosclerotic Plaque at Necropsy in Patients with Lower Extremity Amputation Gisela C. Mautner, MD, Susanne L. Mautner, MD, and William C. Roberts, MD
In 26 patients (mean age at death 66 f 9 years) who had undergone amputatfon (at mean age 63 f 12 years) of 1 or both lower extremities due to severe peripheral arterial atherosckosts, the amounts of narrowing at necropsy in the 4 major (left main, left anterior descending, left circumflex, and right) epicardial coronary arteries were determined. During life, 15 of the 26 patients (S6%) had symptoms of myocardial ischemia: angins pectorts alone in 1, acute myocardial infarction alone in 5, and angina and/or infarction plus congestive heart failure or sudden coronary death in 9. Twelve of the 26 patients (42%) died from consequences of myocardial fschemia: acute myocardial infarction in 5, sudden coronary death in 3, chronic congestive heart failure in 3, and shortly after coronary bypass surgery in 1. Grossly v/sibte teft ventricular necrosts or ftbrosts, or both, was present in 21 patients (81%). Of the 26 patients, 24 (92%) had narrowing 76 to 100% in cross-secttonal area of 1 or more major coronary artertes by atherosclerotic plaque. The mean number of coronary arteries per patient severdy (>75%) narrowed was 2.3 f 1.0/4.0. Of the 104 major coronary arteries in the 26 patients, 60 (58%) were narrowed >7S% in cross-sectional area by plaque. The 4 major coronary arteries in the 26 patients were divfded into S-mm segments and a histologic sect/on, stained by the Movat method, was prepared from each segment. The mean percentages of the resulting 1,222 five-mm segments narrowed in cross-sectional area 0 to 2S%, 26 to SO%, 51 to 7S%, 76 to 95% and 96 to 100% were 17,20,3S, 19 and S%, respectiveiy. The percentages of S-mm coronary segments narrowed >7S% in cross-se&tonal area were dmilar in the left anterior descending, left circumflex and right coronary artertes. Thus, patients with peripheral artertal atherosckrods severe enough to warrant amputation nearly always have diffuse and severe coronary atheroscferosfs at the ttme of necropsy. (Am J Cardioi 1992;70:1147-1151)
I
t is well known that personswith atherosclerotic involvement of 1 arterial system frequently also have atherosclerotic involvement of 1 or more other arterial systems.Persons,for example, with peripheral arterial diseaseoften have evidenceof myocardial ischemia and vice versa. Indeed, coronary artery diseaseis a major cause of death in patients with known abdominal aortic aneurysm or vascular diseaseperipheral to the aorta. Despite the common occurrence of significant amounts of atherosclerosisin more than 1 vascular system, relatively little information is available on the actual amounts of atherosclerotic involvement in a vascular systemother than the one actually causing symptomsof organ ischemia. In the present study we examined in detail the amounts of coronary arterial narrowing by atherosclerotic plaque in patients who had peripheral arterial diseaseby atherosclerosissevereenough to warrant amputation of 1 or both lower limbs. Such a study has not been reported previously. ME7HODS Seurces of patiwts
and general characterfstksr
Records from the Pathology Branch, National Heart, Lung, and Blood Institute, were searched for casesof amputation of the lower extremity due to severeperipheral arterial atherosclerotic disease.A total of 30 cases of lower extremity amputation were retrieved. Two caseswere eliminated becausethe patients were 75% in Cross-Sectional Area
I
ofthellpauentslvfrhft ischada(c8sesltoll,T~
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
AP
AMI
SCD
CHF
CS
DM
0 0 0 0 0 0 0 0 0 0 0 + 0 0 + 0 + + 0 0 + 0 + 0 0
0 0 0 0 0 0 0 0 0 0 0 0 + + 0 + + + + + + + 0 + + +
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 + 0 0 0 + 0 0
0 0 0 0 0 0 0 0 0 0 0 + + 0 + 0 0 0 0 0 + 0 0 0 + 0
+ + + 0 + + + + + + -
0 + 0 0 + 0 0 0 i 0 0 + 0 0 0 + 0 + 0 0 + 0 + 0
6
12
2
5
9
8
Examination of ths heart: The hearts were fmed in 10% buffered formalin for 124 hours before weighing and examination. The major (left main, left anterior descending,left circumflex, and right) epicardial coronary arteries were excised intact after fmation. The arteries then were decalcified, if necessary,with formic acid-sodium citrate for 224 hours. The coronary arteries then were cut transversely into 5-mm-long segmentsand labeled sequentially from origin to termination by a method described elsewhere.2The 5-mm segmentswere dehydrated in ethanol and xylene, and embeddedin paraffin. At least 6 pm thick histologic sections were cut from each 5-mm segment and stained by the Movat method. The percent cross-sectionalarea luminal narrowing by atherosclerotic plaque was determined by microscopic examination with approximately 40 times magnification. The percent luminal narrowing was graded into 1 of 5 cross-sectionalarea categories:0 to 25, 26 to 50, 51 to 75, 76 to 95 and 96 to 100%.The accuracy of this technique of grading cross-sectional area narrowing has been validated to be >95R3 Histologic sections, 22 per heart, extending from endocardium to epicardium of the left ventricular wall, were prepared. Foci of myocardial necrosisor fibrosis, or both, were confirmed histologically. n-"-'e Grossly visibls Ml vcmtriatlar
wall necrosis
or fi-
broais, or both: Two patients (8%) had left ventricular foci of necrosis alone, 15 (58%) had foci of fibrosis NOVEMBER 1, 1992
r TABLE
I (continued)
Case No.
HW
LV Wall N F
Number of CAs J >?5%
No. of 5-mm CA Segments
Number (%) of Coronary Segments Narrowed by Plaque
S
SH
(g)
O-25%
26-50%
51-75%
76-95%
96-100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
0 0 0 0 0 0 + + 0 + 0 0 0 + 0 0 0 0 + -
+ 0 + + + + + 0 0 + + 0 0 + + + + + -
0 -
+ -
0 + 0 -
0 0 + 0
770 370 600 490 660 380 405 490 560 495 350 650 410 405 645 430 450 480 475 350 595 510 450 430 595 330
0 0 0 0 + 0 0 0 + 0 0 0 0 + 0 0 + 0 0 0 0 + 0 0 + 0
f + 0 + + + + 0 + 0 0 + + 0 0 + + + + + + 0 + + + +
3 3 2 2 3 2 3 1 2 0 0 3 2 4 1 3 3 3 2 3 3 2 3 3 2 2
65 48 41 53 37 59 49 39 53 50 53 52 65 59 38 42 65 47 47 56 47 43 61 45 56 52
2 (3) 2 (4) 8 (19) 18 (34) 11 (30) 25 (43) 4 (9) 2 (5) 10 (19) 40 (80) 16 (30) 6(11) 4 (6) 8 (13) 25 (66) 13 (31) 0 0 1 (2) 7 (13) 3 (6) 2 (5) 3 (5) 12 (27) 0 11 (21)
24 (37) 3 (6) 4 (10) 10 (19) 4 (11) 6 (10) 11 (22) 19 (49) 12 (23) 6 (12) 22 (42) 3 (6) 13 (20) 9 (15) 8 (21) 1 (2) 18 (28) 9 (19) 9 (19) 5 (9) 11 (23) 4 (9) 14 (23) 1 (2) 14 (25) 24 (46)
35 21 14 19 10 22 23 17 15 4 15 12 30 21 4 11 16 14 24 14 20 31 13 18 25 10
4 (6) 20 (42) 6 (15) 6 (11) 10 (27) 6 (10) 11 (22) 1 (2) 15 (28) 0 0 17 (33) 8 (12) 11 (19) 1 (3) 10 (24) 20 (31) 20 (43) 8 (17) 12 (21) 12 (26) 6 (14) 19 (31) 12 (27) 14 (25) 1 (2)
0 2 9 0 2 0 0 0 1 0 0 14 10 10 0 7 11 4 5 18 1 0 12 2 3 6
Totals or mean
6
15
491 + 113
6
19
2.3 + 1.0
1,322 (51)
233 (17%)
-
264 (20%)
(54) (44) (34) (36) (27) (37) (47) (44) (28) (8) (28) (23) (46) (36) (10) (26) (24) (30) (51) (25) (43) (72) (21) (40) (45) (19)
458 (35%)
250 (19%)
(4) (22) (5)
(2)
(27) (16) (17) (17) (17) (8) (11) (32) (2) (20) (4) (5) (12)
117 (9%)
AK = above knee; AMI = acute myocardial infarctlon: AP = angina pectoris; B = black; BK = below knee; CA = coronary atiery; CHF = congesbve heart failure; CS = cigarette smoker: DM = diabetes mellitus (adult onset); F = fibrosis; HW = heart weight; LV = left ventricular; N = necrosis; S = stroke; SCD = sudden coronary death; SH = systemic hypertension; W = white.
alone, and 4 patients (15%) had foci of both necrosis and fibrosis. Coronuy &eriesr In the 26 patients, the mean number of coronary arteries per patient narrowed >75% in cross-sectionalarea by atherosclerotic plaque was 2.3 f 1.0: 2 patients (8%) had no arteries narrowed to this degree,2 patients (8%) had 1 artery so narrowed, 9 (34%) had 2 arteries so narrowed, 12 (46%) had 3 arteries so narrowed, and 1 patient (4%) had 4 arteries so narrowed (Figure 1). Of the 24 patients with >75% narrowing of 1 or more major coronary arteries, the number/patient narrowed >75% was 2.5 f 0.7. Of the 104 major epicardial coronary arteries in the 26 patients (4 per patient), 60 (58%) were narrowed by plaque at some point 76 to 100% in cross-sectionalarea. Of the individual major coronary arteries, the left main coronary artery was severelynarrowed (76 to 100%in crosssectional area) in 1 patient (4%), the left anterior descending coronary artery in 2 1 patients (8 l%), the left circumflex coronary artery in 17 patients (65%), and the right coronary artery in 21 patients (81%). Of the 1,322 five-mm-long coronary segments from the 104 major coronary arteries, the mean percentages narrowed in cross-sectionalarea 0 to 25%, 26 to 50%, 51 to 75%, 76 to 95% and 96 to 100%were 17,20,35, 19 and 9%, respectively. The amount of narrowing in all 5-mm segmentsand in each major coronary artery in the pa-
7::
No. PatIenta No. S-mm Segments
ioo-
80 -
n q n q
60 -
96-100%
76-95%
51-75% 26-50% 0 O-25%
40-
20 -
0
+
Clinical signs of myocardial
1 FIGURE __. _ 2. _Mea ~of5-mm~oftheslml _ _ -lllWOWMltOV~~ ~-4VcoronrY
ischemia
__
.
_
h-m(CSA)ln25rmprtaer:~ol
llpdent8w~(-ltolI,T~I)withl5~
a (i&emia.
12 b 28, TW 1)w
m
d m
CORONARY NARROWING OF AMPUTEES
1149
FIGURE 3. Coqdsom
of lnan
pameat-
agesuf5-mlnsegmdsoflhe4major ~-MWOWdlOV~ds-
greeshrmwwtbdracl(CSA)ln26
~eomprironOfllpdkHltS wifhout(-ltoll,TabbI)nd15 pdentslvEll,(c8sesl2to2B,T~I) cblkdavldemeof~kdBmlh. 0
+
Left Mam
0
+
Left Anterior Descending
0
+
Left Circumflex
0
+
Myocardial
Rtght
lschemia
Coronary Arleries
tients with and without clinical evidenceof myocardial ischemia is summarized in Figures 2 and 3. DISCUSSION
sUllmalyofmrrjoriMingsintheprefentstudyrOf the 26 amputees, 24 (92%) had 1 or more coronary arteries narrowed >75% in cross-sectional area by plaque, an average of 2.5 f 0.7 for each of the 24 patients. The left anterior descending,left circumflex, and right coronary artery had similar amounts of severecoronary narrowing (35, 28 and 35%, respectively). Of a total of 1,322 five-mm segmentsof the 4 major coronary arteries, 28% were narrowed 76 to 100%in crosssectional area. Although the numbers of coronary arteries narrowed >75% in cross-sectionalarea by plaque were not significantly different in the 15 patients with compared to the 11 patients without clinical evidenceof myocardial ischemia (2.6 f 0.7 vs 1.9 f 1.1, p = 0.07), the percentage of 5-mm coronary segmentsnarrowed >75% was significantly greater in patients with compared to those without clinical evidence of myocardial ischemia (35 vs 17%, p = 0.02). Twenty-one of the 26 patients at necropsyhad acute and/or healed myocardial infarcts. The 21 patients with myocardial infarcts had more coronary narrowing by plaque than did the 5 patients without (mean numbers of coronary arteries narrowed >75% = 2.7 f 0.6 vs 0.8 f 0.8, p = 0.0001; 5-mm segments narrowed >75% = 32 vs 8%, p = 0.006). sludlesonthecoroReviwrtrraported-
onary angiography in 28 men (aged 26 to 70 years [mean 561) with symptomatic peripheral arterial disease: only 3 patients (11%) had coronary narrowing >50% in diameter. Tomatis et all6 in 1972 reported findings on coronary angiograms in 72 patients (aged 39 to 76 years [mean 581) with symptomatic peripheral vascular disease:34 patients (47%) had narrowing 76 to 100%in diameter of 1 or more major coronary arteries, 7 patients (10%) had narrowing 51 to 75%, and the remaining 31 patients (43%) had insignificant (150% diameter reduction) coronary narrowing. Hertzer et all7 in 1984 describedcoronary angiographic findings in 381 patients (aged 29 to 90 years [mean 621) with peripheral vascular disease:218 (57%) had narrowing >70% in diameter of 1 or more major coronary arteries, another 125 patients (33%) had 1 or more narrowings between “measurable” to 70% diameter reduction, and the remaining 38 patients (10%) had “angiographically normal” arteries. Although the present study in many ways is quite different from the one reported by Hertzer et a1,r7comparison of our study to theirs is neverthelessappropriate in some areas:frequency of the presence of 1 or more major coronav arteries signijkantly
(>75% cross-sec-
tional area narrowing at necropsyand >50% in diameter at angiography) narrowed (24 of 26 patients [920/o] vs 343 of 381 patients [9O%]);fre4uency of single, dou-
ble and triple (or quadruple) coronary arterial narrowing (8, 34 and 50% vs 21, 20 and 18%, respectively); frequency of signijkant narrowing of the 1ejI main, left neyartehslnpathtswRhpedphedvasadardl*anterior descending, left circumflex and right coronary emewithandwiulout cunputrtion: No previously re- arteries (2, 35, 28 and 35% vs 4, 30, 35 and 46%, reported study has examined at necropsy the amounts of spectively); and frequency of clinical evidence of myocoronary narrowing in patients having previous lower cardial ischemia (58 vs 56%).
limb amputation. hWmJ0-d inpathbwith~
-ryanlBh?re* paripheral
arledal
ath-
AeknowWgmenk We appreciate the excellent secretarial assistanceof Vivian Norman, and the technical assistanceof Filippina Giacometti and Leslie Berry.
m di~se: Although a number have described the frequency of clinical evidence of myocardial ischemia in patients with peripheral arterial disease,4-14few previously published studies have reported REFERENCES the amounts of coronary narrowing by angiogram in pa- 1. Roberts WC. Sudden cardiac death: a diversity of causes with focus on atherocoronary artery disease. Am J Cwdiol 1990;65:13B-19B. tients with intermittent claudication or lower limb tissue sclerotic 2. Roberts WC. Qualitative and quantitative comparison of amounts of narrownecrosis,or both. Schoop et all5 in 1966 performed cor- ing by atherosclerotic plaques in the major epicardial coronary arteries at necrop i 150
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
NOVEMBER 1. 1992
sy in sudden coronary death, transmural acute myocardial infarction, transmural healed myocardial infarction and unstable angina pectoris. Am J Cardiol 1989;64:324-328. 3. Isner JM, Wu M, Virmani R, Jones AA, Roberts WC. Comparison of degrees of coronary arterial luminal narrowing determined by visual inspection of histe logic sections under magnification among three independent observers and comparison to that obtained by video planimetry: an analysis of 559 five-millimeter segments of 61 coronary arteries from eleven patients. Lab Invest 1980:42: 566-570. 4. McDonald L. Ischaemic heart disease and peripheral occlusive arterial disease. Br Hear? J 1953;15:101-107. 5. Richards RL. Prognosis of intermittent claudication. Br Med J 1957;2: 1091-1093. 6. Juergens JL, Barker NW, Hines EA Jr. Arteriosclerosis obliterans: review of 520 cases with special reference to pathogenic and prognostic factors. Circulation 1960;21:188-195. 7. Tillgren C. Obliterative arterial disease of the lower limbs. III. Prognostic influence of concomitant coronary heart disease. Acfo Med Stand 1965;178: 121-128. 8. Cooperman M, PfIug B, Martin EW, Evans WE. Cardiovascular risk factors in patients with peripheral vascular die. Surgery 1978;84:505-509. 9. DeBakey ME, Lawrie GM. Combined coronary artery and peripheral vascular
disease: recognition and treatment. J VOX Surg 1984;1:605-607. 10. Kannel WB, McGee DL. Update on some epidemiologic features of intermittent claudication: the Framingham study. J Am Geriot Sot 1985;33:13-18. 11. La&la R, LeNntalo M, Lindfors 0. Peripheral arterial disease-natural outcome. Acre .&ted Scmd 1986;220:295-301. 12. Hertzer NR. Basic data concerning associated coronary disease in peripheral vascular patients. Ann Varr Surg 1987;1:616-620. 13. Ledingham JGG. Peripheral vascular disease as a risk factor for ischaemic heart disease. Eur Heart J 1988;9(suppl G):65-68. 14. Gersh BJ, Rihal CS, Rooke TW, Ballard DJ. Evaluation and management of patients with both peripheral vascular and coronary artery disease. J Am Co11 Cardiol 1991;18:203-214. 15. Schoop W, Kiefer H, Bliimchen G. Koronarangiographische Befunde bei Kranken mit obliterierenden Verinderungen in den Extremititenarterien und normalem Ruhe-EKG. Z Kreislauf Forsch 1966;55:884-890. 16. Tomatis LA, Fierens EE, Verbrugge GP. Evaluation of surgical risk in peripheral vascular disease by coronary arteriography: a series of 100 cases. Surgery 1972;71:429-435. 17. Her&r NR, Beven EG, Young JR, O’Hara PJ, Ruschhaupt III WF, Graor RA, DeWolfe VG, Maljovec LC. Coronary artery disease in peripheral vascular patients: a classification of 1000 coronary angiograms and results of surgical management. Ann Surg 1984;199:223-233.
CORONARY NARROWING OF AMPUTEES
1151
In 26 patients (mean age at death 66 f 9 years) who had undergone amputatfon (at mean age 63 f 12 years) of 1 or both lower extremities due to severe peripheral arterial atherosckosts, the amounts of narrowing at necropsy in the 4 major (left main, left anterior descending, left circumflex, and right) epicardial coronary arteries were determined. During life, 15 of the 26 patients (S6%) had symptoms of myocardial ischemia: angins pectorts alone in 1, acute myocardial infarction alone in 5, and angina and/or infarction plus congestive heart failure or sudden coronary death in 9. Twelve of the 26 patients (42%) died from consequences of myocardial fschemia: acute myocardial infarction in 5, sudden coronary death in 3, chronic congestive heart failure in 3, and shortly after coronary bypass surgery in 1. Grossly v/sibte teft ventricular necrosts or ftbrosts, or both, was present in 21 patients (81%). Of the 26 patients, 24 (92%) had narrowing 76 to 100% in cross-secttonal area of 1 or more major coronary artertes by atherosclerotic plaque. The mean number of coronary arteries per patient severdy (>75%) narrowed was 2.3 f 1.0/4.0. Of the 104 major coronary arteries in the 26 patients, 60 (58%) were narrowed >7S% in cross-sectional area by plaque. The 4 major coronary arteries in the 26 patients were divfded into S-mm segments and a histologic sect/on, stained by the Movat method, was prepared from each segment. The mean percentages of the resulting 1,222 five-mm segments narrowed in cross-sectional area 0 to 2S%, 26 to SO%, 51 to 7S%, 76 to 95% and 96 to 100% were 17,20,3S, 19 and S%, respectiveiy. The percentages of S-mm coronary segments narrowed >7S% in cross-se&tonal area were dmilar in the left anterior descending, left circumflex and right coronary artertes. Thus, patients with peripheral artertal atherosckrods severe enough to warrant amputation nearly always have diffuse and severe coronary atheroscferosfs at the ttme of necropsy. (Am J Cardioi 1992;70:1147-1151)
I
t is well known that personswith atherosclerotic involvement of 1 arterial system frequently also have atherosclerotic involvement of 1 or more other arterial systems.Persons,for example, with peripheral arterial diseaseoften have evidenceof myocardial ischemia and vice versa. Indeed, coronary artery diseaseis a major cause of death in patients with known abdominal aortic aneurysm or vascular diseaseperipheral to the aorta. Despite the common occurrence of significant amounts of atherosclerosisin more than 1 vascular system, relatively little information is available on the actual amounts of atherosclerotic involvement in a vascular systemother than the one actually causing symptomsof organ ischemia. In the present study we examined in detail the amounts of coronary arterial narrowing by atherosclerotic plaque in patients who had peripheral arterial diseaseby atherosclerosissevereenough to warrant amputation of 1 or both lower limbs. Such a study has not been reported previously. ME7HODS Seurces of patiwts
and general characterfstksr
Records from the Pathology Branch, National Heart, Lung, and Blood Institute, were searched for casesof amputation of the lower extremity due to severeperipheral arterial atherosclerotic disease.A total of 30 cases of lower extremity amputation were retrieved. Two caseswere eliminated becausethe patients were 75% in Cross-Sectional Area
I
ofthellpauentslvfrhft ischada(c8sesltoll,T~
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
AP
AMI
SCD
CHF
CS
DM
0 0 0 0 0 0 0 0 0 0 0 + 0 0 + 0 + + 0 0 + 0 + 0 0
0 0 0 0 0 0 0 0 0 0 0 0 + + 0 + + + + + + + 0 + + +
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 + 0 0 0 + 0 0
0 0 0 0 0 0 0 0 0 0 0 + + 0 + 0 0 0 0 0 + 0 0 0 + 0
+ + + 0 + + + + + + -
0 + 0 0 + 0 0 0 i 0 0 + 0 0 0 + 0 + 0 0 + 0 + 0
6
12
2
5
9
8
Examination of ths heart: The hearts were fmed in 10% buffered formalin for 124 hours before weighing and examination. The major (left main, left anterior descending,left circumflex, and right) epicardial coronary arteries were excised intact after fmation. The arteries then were decalcified, if necessary,with formic acid-sodium citrate for 224 hours. The coronary arteries then were cut transversely into 5-mm-long segmentsand labeled sequentially from origin to termination by a method described elsewhere.2The 5-mm segmentswere dehydrated in ethanol and xylene, and embeddedin paraffin. At least 6 pm thick histologic sections were cut from each 5-mm segment and stained by the Movat method. The percent cross-sectionalarea luminal narrowing by atherosclerotic plaque was determined by microscopic examination with approximately 40 times magnification. The percent luminal narrowing was graded into 1 of 5 cross-sectionalarea categories:0 to 25, 26 to 50, 51 to 75, 76 to 95 and 96 to 100%.The accuracy of this technique of grading cross-sectional area narrowing has been validated to be >95R3 Histologic sections, 22 per heart, extending from endocardium to epicardium of the left ventricular wall, were prepared. Foci of myocardial necrosisor fibrosis, or both, were confirmed histologically. n-"-'e Grossly visibls Ml vcmtriatlar
wall necrosis
or fi-
broais, or both: Two patients (8%) had left ventricular foci of necrosis alone, 15 (58%) had foci of fibrosis NOVEMBER 1, 1992
r TABLE
I (continued)
Case No.
HW
LV Wall N F
Number of CAs J >?5%
No. of 5-mm CA Segments
Number (%) of Coronary Segments Narrowed by Plaque
S
SH
(g)
O-25%
26-50%
51-75%
76-95%
96-100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
0 0 0 0 0 0 + + 0 + 0 0 0 + 0 0 0 0 + -
+ 0 + + + + + 0 0 + + 0 0 + + + + + -
0 -
+ -
0 + 0 -
0 0 + 0
770 370 600 490 660 380 405 490 560 495 350 650 410 405 645 430 450 480 475 350 595 510 450 430 595 330
0 0 0 0 + 0 0 0 + 0 0 0 0 + 0 0 + 0 0 0 0 + 0 0 + 0
f + 0 + + + + 0 + 0 0 + + 0 0 + + + + + + 0 + + + +
3 3 2 2 3 2 3 1 2 0 0 3 2 4 1 3 3 3 2 3 3 2 3 3 2 2
65 48 41 53 37 59 49 39 53 50 53 52 65 59 38 42 65 47 47 56 47 43 61 45 56 52
2 (3) 2 (4) 8 (19) 18 (34) 11 (30) 25 (43) 4 (9) 2 (5) 10 (19) 40 (80) 16 (30) 6(11) 4 (6) 8 (13) 25 (66) 13 (31) 0 0 1 (2) 7 (13) 3 (6) 2 (5) 3 (5) 12 (27) 0 11 (21)
24 (37) 3 (6) 4 (10) 10 (19) 4 (11) 6 (10) 11 (22) 19 (49) 12 (23) 6 (12) 22 (42) 3 (6) 13 (20) 9 (15) 8 (21) 1 (2) 18 (28) 9 (19) 9 (19) 5 (9) 11 (23) 4 (9) 14 (23) 1 (2) 14 (25) 24 (46)
35 21 14 19 10 22 23 17 15 4 15 12 30 21 4 11 16 14 24 14 20 31 13 18 25 10
4 (6) 20 (42) 6 (15) 6 (11) 10 (27) 6 (10) 11 (22) 1 (2) 15 (28) 0 0 17 (33) 8 (12) 11 (19) 1 (3) 10 (24) 20 (31) 20 (43) 8 (17) 12 (21) 12 (26) 6 (14) 19 (31) 12 (27) 14 (25) 1 (2)
0 2 9 0 2 0 0 0 1 0 0 14 10 10 0 7 11 4 5 18 1 0 12 2 3 6
Totals or mean
6
15
491 + 113
6
19
2.3 + 1.0
1,322 (51)
233 (17%)
-
264 (20%)
(54) (44) (34) (36) (27) (37) (47) (44) (28) (8) (28) (23) (46) (36) (10) (26) (24) (30) (51) (25) (43) (72) (21) (40) (45) (19)
458 (35%)
250 (19%)
(4) (22) (5)
(2)
(27) (16) (17) (17) (17) (8) (11) (32) (2) (20) (4) (5) (12)
117 (9%)
AK = above knee; AMI = acute myocardial infarctlon: AP = angina pectoris; B = black; BK = below knee; CA = coronary atiery; CHF = congesbve heart failure; CS = cigarette smoker: DM = diabetes mellitus (adult onset); F = fibrosis; HW = heart weight; LV = left ventricular; N = necrosis; S = stroke; SCD = sudden coronary death; SH = systemic hypertension; W = white.
alone, and 4 patients (15%) had foci of both necrosis and fibrosis. Coronuy &eriesr In the 26 patients, the mean number of coronary arteries per patient narrowed >75% in cross-sectionalarea by atherosclerotic plaque was 2.3 f 1.0: 2 patients (8%) had no arteries narrowed to this degree,2 patients (8%) had 1 artery so narrowed, 9 (34%) had 2 arteries so narrowed, 12 (46%) had 3 arteries so narrowed, and 1 patient (4%) had 4 arteries so narrowed (Figure 1). Of the 24 patients with >75% narrowing of 1 or more major coronary arteries, the number/patient narrowed >75% was 2.5 f 0.7. Of the 104 major epicardial coronary arteries in the 26 patients (4 per patient), 60 (58%) were narrowed by plaque at some point 76 to 100% in cross-sectionalarea. Of the individual major coronary arteries, the left main coronary artery was severelynarrowed (76 to 100%in crosssectional area) in 1 patient (4%), the left anterior descending coronary artery in 2 1 patients (8 l%), the left circumflex coronary artery in 17 patients (65%), and the right coronary artery in 21 patients (81%). Of the 1,322 five-mm-long coronary segments from the 104 major coronary arteries, the mean percentages narrowed in cross-sectionalarea 0 to 25%, 26 to 50%, 51 to 75%, 76 to 95% and 96 to 100%were 17,20,35, 19 and 9%, respectively. The amount of narrowing in all 5-mm segmentsand in each major coronary artery in the pa-
7::
No. PatIenta No. S-mm Segments
ioo-
80 -
n q n q
60 -
96-100%
76-95%
51-75% 26-50% 0 O-25%
40-
20 -
0
+
Clinical signs of myocardial
1 FIGURE __. _ 2. _Mea ~of5-mm~oftheslml _ _ -lllWOWMltOV~~ ~-4VcoronrY
ischemia
__
.
_
h-m(CSA)ln25rmprtaer:~ol
llpdent8w~(-ltolI,T~I)withl5~
a (i&emia.
12 b 28, TW 1)w
m
d m
CORONARY NARROWING OF AMPUTEES
1149
FIGURE 3. Coqdsom
of lnan
pameat-
agesuf5-mlnsegmdsoflhe4major ~-MWOWdlOV~ds-
greeshrmwwtbdracl(CSA)ln26
~eomprironOfllpdkHltS wifhout(-ltoll,TabbI)nd15 pdentslvEll,(c8sesl2to2B,T~I) cblkdavldemeof~kdBmlh. 0
+
Left Mam
0
+
Left Anterior Descending
0
+
Left Circumflex
0
+
Myocardial
Rtght
lschemia
Coronary Arleries
tients with and without clinical evidenceof myocardial ischemia is summarized in Figures 2 and 3. DISCUSSION
sUllmalyofmrrjoriMingsintheprefentstudyrOf the 26 amputees, 24 (92%) had 1 or more coronary arteries narrowed >75% in cross-sectional area by plaque, an average of 2.5 f 0.7 for each of the 24 patients. The left anterior descending,left circumflex, and right coronary artery had similar amounts of severecoronary narrowing (35, 28 and 35%, respectively). Of a total of 1,322 five-mm segmentsof the 4 major coronary arteries, 28% were narrowed 76 to 100%in crosssectional area. Although the numbers of coronary arteries narrowed >75% in cross-sectionalarea by plaque were not significantly different in the 15 patients with compared to the 11 patients without clinical evidenceof myocardial ischemia (2.6 f 0.7 vs 1.9 f 1.1, p = 0.07), the percentage of 5-mm coronary segmentsnarrowed >75% was significantly greater in patients with compared to those without clinical evidence of myocardial ischemia (35 vs 17%, p = 0.02). Twenty-one of the 26 patients at necropsyhad acute and/or healed myocardial infarcts. The 21 patients with myocardial infarcts had more coronary narrowing by plaque than did the 5 patients without (mean numbers of coronary arteries narrowed >75% = 2.7 f 0.6 vs 0.8 f 0.8, p = 0.0001; 5-mm segments narrowed >75% = 32 vs 8%, p = 0.006). sludlesonthecoroReviwrtrraported-
onary angiography in 28 men (aged 26 to 70 years [mean 561) with symptomatic peripheral arterial disease: only 3 patients (11%) had coronary narrowing >50% in diameter. Tomatis et all6 in 1972 reported findings on coronary angiograms in 72 patients (aged 39 to 76 years [mean 581) with symptomatic peripheral vascular disease:34 patients (47%) had narrowing 76 to 100%in diameter of 1 or more major coronary arteries, 7 patients (10%) had narrowing 51 to 75%, and the remaining 31 patients (43%) had insignificant (150% diameter reduction) coronary narrowing. Hertzer et all7 in 1984 describedcoronary angiographic findings in 381 patients (aged 29 to 90 years [mean 621) with peripheral vascular disease:218 (57%) had narrowing >70% in diameter of 1 or more major coronary arteries, another 125 patients (33%) had 1 or more narrowings between “measurable” to 70% diameter reduction, and the remaining 38 patients (10%) had “angiographically normal” arteries. Although the present study in many ways is quite different from the one reported by Hertzer et a1,r7comparison of our study to theirs is neverthelessappropriate in some areas:frequency of the presence of 1 or more major coronav arteries signijkantly
(>75% cross-sec-
tional area narrowing at necropsyand >50% in diameter at angiography) narrowed (24 of 26 patients [920/o] vs 343 of 381 patients [9O%]);fre4uency of single, dou-
ble and triple (or quadruple) coronary arterial narrowing (8, 34 and 50% vs 21, 20 and 18%, respectively); frequency of signijkant narrowing of the 1ejI main, left neyartehslnpathtswRhpedphedvasadardl*anterior descending, left circumflex and right coronary emewithandwiulout cunputrtion: No previously re- arteries (2, 35, 28 and 35% vs 4, 30, 35 and 46%, reported study has examined at necropsy the amounts of spectively); and frequency of clinical evidence of myocoronary narrowing in patients having previous lower cardial ischemia (58 vs 56%).
limb amputation. hWmJ0-d inpathbwith~
-ryanlBh?re* paripheral
arledal
ath-
AeknowWgmenk We appreciate the excellent secretarial assistanceof Vivian Norman, and the technical assistanceof Filippina Giacometti and Leslie Berry.
m di~se: Although a number have described the frequency of clinical evidence of myocardial ischemia in patients with peripheral arterial disease,4-14few previously published studies have reported REFERENCES the amounts of coronary narrowing by angiogram in pa- 1. Roberts WC. Sudden cardiac death: a diversity of causes with focus on atherocoronary artery disease. Am J Cwdiol 1990;65:13B-19B. tients with intermittent claudication or lower limb tissue sclerotic 2. Roberts WC. Qualitative and quantitative comparison of amounts of narrownecrosis,or both. Schoop et all5 in 1966 performed cor- ing by atherosclerotic plaques in the major epicardial coronary arteries at necrop i 150
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
NOVEMBER 1. 1992
sy in sudden coronary death, transmural acute myocardial infarction, transmural healed myocardial infarction and unstable angina pectoris. Am J Cardiol 1989;64:324-328. 3. Isner JM, Wu M, Virmani R, Jones AA, Roberts WC. Comparison of degrees of coronary arterial luminal narrowing determined by visual inspection of histe logic sections under magnification among three independent observers and comparison to that obtained by video planimetry: an analysis of 559 five-millimeter segments of 61 coronary arteries from eleven patients. Lab Invest 1980:42: 566-570. 4. McDonald L. Ischaemic heart disease and peripheral occlusive arterial disease. Br Hear? J 1953;15:101-107. 5. Richards RL. Prognosis of intermittent claudication. Br Med J 1957;2: 1091-1093. 6. Juergens JL, Barker NW, Hines EA Jr. Arteriosclerosis obliterans: review of 520 cases with special reference to pathogenic and prognostic factors. Circulation 1960;21:188-195. 7. Tillgren C. Obliterative arterial disease of the lower limbs. III. Prognostic influence of concomitant coronary heart disease. Acfo Med Stand 1965;178: 121-128. 8. Cooperman M, PfIug B, Martin EW, Evans WE. Cardiovascular risk factors in patients with peripheral vascular die. Surgery 1978;84:505-509. 9. DeBakey ME, Lawrie GM. Combined coronary artery and peripheral vascular
disease: recognition and treatment. J VOX Surg 1984;1:605-607. 10. Kannel WB, McGee DL. Update on some epidemiologic features of intermittent claudication: the Framingham study. J Am Geriot Sot 1985;33:13-18. 11. La&la R, LeNntalo M, Lindfors 0. Peripheral arterial disease-natural outcome. Acre .&ted Scmd 1986;220:295-301. 12. Hertzer NR. Basic data concerning associated coronary disease in peripheral vascular patients. Ann Varr Surg 1987;1:616-620. 13. Ledingham JGG. Peripheral vascular disease as a risk factor for ischaemic heart disease. Eur Heart J 1988;9(suppl G):65-68. 14. Gersh BJ, Rihal CS, Rooke TW, Ballard DJ. Evaluation and management of patients with both peripheral vascular and coronary artery disease. J Am Co11 Cardiol 1991;18:203-214. 15. Schoop W, Kiefer H, Bliimchen G. Koronarangiographische Befunde bei Kranken mit obliterierenden Verinderungen in den Extremititenarterien und normalem Ruhe-EKG. Z Kreislauf Forsch 1966;55:884-890. 16. Tomatis LA, Fierens EE, Verbrugge GP. Evaluation of surgical risk in peripheral vascular disease by coronary arteriography: a series of 100 cases. Surgery 1972;71:429-435. 17. Her&r NR, Beven EG, Young JR, O’Hara PJ, Ruschhaupt III WF, Graor RA, DeWolfe VG, Maljovec LC. Coronary artery disease in peripheral vascular patients: a classification of 1000 coronary angiograms and results of surgical management. Ann Surg 1984;199:223-233.
CORONARY NARROWING OF AMPUTEES
1151
