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Aortic arch aneurysm complicated with coronary artery disease: still a surgical challenge?
1Department of Cardiovascular Surgery, Fukushima Medical University, Japan.
Insights
Simultaneous aortic arch repair (AAR) and coronary artery bypass grafting (CABG) is challenging. Off-pump CABG with AAR using selective cerebral perfusion (SCP) improved outcomes by reducing cardiac ischemic and cardiopulmonary times.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Aortic arch aneurysm (AAA) with coronary artery disease (CAD) presents complex surgical challenges.
- Simultaneous aortic arch repair (AAR) and coronary artery bypass grafting (CABG) carry higher mortality risks than AAR alone, despite advancements in cerebral protection.
- Minimizing cardiac ischemic time is crucial for improving outcomes in these high-risk patients.
Purpose of the Study:
- To review recent surgical strategies and outcomes for combined AAR and CABG.
- To evaluate techniques aimed at reducing operative complexity and improving patient safety.
- To identify less-invasive modalities for better myocardial protection and reduced cardiopulmonary bypass effects.
Main Methods:
- Review of recent surgical strategies for simultaneous AAR and CABG.
- Analysis of techniques to minimize cardiac ischemic time, including distal coronary anastomosis on a beating heart and cardioplegic perfusion.
- Evaluation of novel approaches like open stent grafting and off-pump CABG with AAR and selective cerebral perfusion (SCP).
Main Results:
- Combined AAR and CABG significantly increases surgical risk and mortality compared to AAR alone.
- Techniques like distal coronary anastomosis and cardioplegic perfusion aim to reduce cardiac ischemic time.
- Off-pump CABG combined with AAR and SCP demonstrated decreased cardiac ischemic and cardiopulmonary times, leading to improved morbidity and mortality.
Conclusions:
- Simultaneous AAR and CABG remains a high-risk procedure, particularly in elderly patients with comorbidities.
- Off-pump CABG with AAR and SCP offers a promising approach to reduce operative time and improve outcomes.
- Further development of less-invasive surgical techniques is essential for enhancing myocardial protection and minimizing cardiopulmonary bypass-related adverse effects in this complex patient population.
Abstract:
Recent surgical strategies and outcomes for the simultaneous operation of aortic arch repair (AAR) and coronary artery bypass grafting (CABG) were reviewed. The surgical treatment of aortic arch aneurysm complicated with coronary artery arteriosclerosis has been a challenge. In spite of recent improvements in cerebral protection during AAR such as deep hypothermia and circulatory arrest with/without retrograde cerebral perfusion, or antegrade selective cerebral perfusion (SCP), additional CABG poses a considerable surgical risk resulting in extremely higher mortality rates when compared with solo AAR. To minimize the cardiac ischemic time, several techniques such as distal coronary artery anastomosis on the perfused fibrillating heart, and coronary artery perfusion through a cardioplegic line during AAR have been employed. Recently, open stent grafting instead of aortic distal anastomosis has been attempted to minimize the cardiopulmonary time and operative complexity. Our recent experience suggested off-pump coronary artery bypass and AAR with the aid of SCP decreased cardiac ischemic time and cardiopulmonary time followed by improved operative morbidity and mortality. Further less-invasive surgical modalities that enhance the adequate myocardial protection and minimize the adverse effect of cardiopulmonary bypass can improve the outcome of this demanding operation for these elderly patients with aortic arch aneurysm and coronary artery occlusive disease.