The CARP trial: Preoperative revascularization prior to elective vascular surgery [Classics Series]

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1. In patients with stable coronary artery disease undergoing elective vascular surgery, preoperative revascularization does not significantly reduce short- or long-term mortality.

2. Patients undergoing revascularization experience significant time delays prior to surgery.

Original Date of Publication: December 30, 2004

Study Rundown: The CARP trial demonstrated that in patients with stable coronary artery disease undergoing elective vascular surgery, pre-operative coronary revascularization does not provide any benefit in terms of reducing the risk of myocardial infarction or mortality (i.e., short- or long-term). Patients undergoing revascularization, however, waited significantly longer before having surgery compared to individuals who did not undergo revascularization (54 vs. 18 days). The findings of this study supported practice guidelines at the time, which recommended that coronary revascularization be reserved for patients with symptomatic coronary artery disease. Given the efficacy of perioperative beta-blockers and statins, medical management may be suitable alternatives to revascularization in patients with asymptomatic coronary artery disease.

Please click to read study in NEJM

In-Depth [randomized, controlled study]: Patients undergoing elective vascular surgery have a high prevalence of coronary artery disease and have high-risk of perioperative cardiac complications. The CARP trial, originally published in 2004 in NEJM, sought to explore the long-term effects of pre-operative coronary revascularization in patients undergoing elective vascular surgery, as retrospective studies until that point had mixed findings. Of the 5,859 patients screened, 510 patients were eligible and underwent randomization. Patients were eligible if they were scheduled for elective vascular surgery (i.e., abdominal aortic aneurysm, severe occlusive arterial disease in the legs) and had stenosis of at least 70% in one or more major coronary artery that was suitable for revascularization (i.e., percutaneous intervention – PCI, coronary artery bypass graft – CABG). The primary endpoint was long-term mortality, as determined by follow-up.

Of the 258 patients who were randomized to the revascularization group, 59% underwent PCI, while 41% underwent CABG. The median time from randomization to surgery was 54 days in the revascularization group and 18 days in the non-revascularization group (P<0.001). There were no significant differences between the groups in terms of the incidence of myocardial infarction or death in the 30 days following surgery. There were no significant differences between the two groups in terms of long-term mortality.

By Adrienne Cheung, Andrew Cheung, M.D.

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