Dear Editor,
We are grateful for the interest in our systematic review from Timbrell et al., who suggest that the value of CPET may lie in identifying those in whom endovascular aneurysm repair (EVAR) may be a safer alternative for patients with abdominal aortic aneurysm (AAA). We disagree with this assertion, as available data increasingly suggest that aneurysm morphology, rather than patient physiology or comorbidity, is the stronger predictor of long-term outcome from EVAR.
1
, 2
, 3
, 4
Early physiological scoring systems for open AAA repair perform with reduced accuracy in patients selected for open repair in the endovascular era.5
While ongoing research has demonstrated the comparative utility of newer scoring systems for predicting the outcome of open AAA repair in contemporary practice,6
no such evidence currently exists for CPET. We therefore reiterate the conclusion that the role of CPET in determining whether patients should undergo open repair, EVAR, or conservative management of AAA, requires investigation in a formal research environment, with appropriate safeguards for patient safety.We appreciate that CPET has its enthusiasts, but if its value is to be better recognised and understood in vascular patients, then its use must be investigated through well-designed research. If units that have routinely used CPET in patients with AAA related their data to outcomes through prospective, local or national registries then the vascular community might develop a greater understanding of its uses and limitations. Timbrell et al. highlighted the mention of CPET within the AAA Quality Improvement Program (AAAQIP) guidance.
7
We support these guidelines but this particular recommendation was based on expert opinion; the guidance does not cite a higher level of evidence to support the inclusion of CPET, and the lack of evidence surrounding the inclusion of CPET prompted the present systematic review. The review itself represents new evidence that might inform revisions to AAAQIP guidance.At present, only 32% of UK hospitals have access to CPET,
8
CPET is not widely used outside the UK, and the predominance of Endovascular Aneurysm Repair has considerably changed the context for physiological risk-stratification of patients with AAA prior to surgery. Nonetheless, population data have suggested that non-invasive cardiac stress testing might confer benefit prior to elective non-cardiac surgery for the subgroup at high risk of perioperative cardiac complications,9
and these data illustrate that the role of CPET in vascular patients deserves focussed investigation. The clear potential of CPET to improve patient selection, optimisation and surgical outcome in vascular surgery remains in need of formal research.References
- Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair.Circulation. 2011; 123: 2848-2855
- Use of baseline factors to predict complications and reinterventions after endovascular repair of abdominal aortic aneurysm.Br J Surg. 2010; 97: 1207-1217
- Predicting risk in elective abdominal aortic aneurysm repair: a systematic review of current evidence.Eur J Vasc Endovasc Surg. 2008; 36: 637-645
- Existing risk prediction methods for elective abdominal aortic aneurysm repair do not predict short-term outcome following endovascular repair.J Vasc Surg. 2010; 52: 25-30
- The Glasgow Aneurysm Score does not predict mortality after open abdominal aortic aneurysm in the era of endovascular aneurysm repair.J Vasc Surg. 2011; 54: 353-357
- Evaluation of five risk prediction models for elective abdominal aortic aneurysm repair using the UK National Vascular Database.Br J Surg. 2012; 99: 673-679
- Framework for improving the results of elective AAA repair. Vascular Society, 2009 (available from:)
Huddart S, Young EL, Pradhu P. A national survey of CPET practice in the UK. In: 4th National Perioperative CPET Meeting. London; 2011.
- Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study.BMJ. 2010; 340: b5526
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Published online: July 16, 2012
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© 2012 European Society for Vascular Surgery. Published by Elsevier Inc.
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- Comment on ‘A Systematic Review of the Role of Cardiopulmonary Exercise Testing in Vascular Surgery’European Journal of Vascular and Endovascular SurgeryVol. 44Issue 3
- PreviewWe read with interest the article by Young et al. and value their contribution to this area of clinical practice.1 We too are of the opinion that more research in this area would be invaluable. However, we are some what surprised regarding the assertion that cardiopulmonary exercise testing (CPET) not be used out of a research environment.
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