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Simultaneous coronary bypass and abdominal aortic surgery in patients with severe coronary disease--indication and
R Autschbach1, V Falk, T Walther
1University Hospital of Cardiac Surgery, Heart Center Leipzig, Germany.
Insights
Simultaneous coronary artery bypass grafting (CABG) and abdominal aortic surgery for severe coronary artery disease (CAD) and abdominal aortic disease is a viable option. This combined approach offers reasonable outcomes for high-risk patients, mitigating risks associated with aortic clamping.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Cardiac Anesthesia
Background:
- Severe coronary artery disease (CAD) and abdominal aortic aneurysms (AAA) or aortic occlusive disease (AOD) often coexist.
- Simultaneous surgical intervention is challenging due to high morbidity and mortality.
- Two-stage procedures are not feasible for all patients with combined CAD and AAA/AOD.
Purpose of the Study:
- To evaluate the safety and efficacy of combined coronary artery bypass graft surgery (CABG) and abdominal aortic surgery.
- To assess outcomes in patients requiring simultaneous intervention for severe CAD and symptomatic AAA or AOD.
Main Methods:
- A series of 29 patients underwent combined CABG and abdominal aortic surgery (25 AAA, 4 AOD).
- CABG was performed first, followed by abdominal aortic surgery (tube or bifurcation grafts) while on partial cardiopulmonary bypass (CPB).
- Intraoperative management and post-operative outcomes were recorded.
Main Results:
- Hospital mortality was 8% in the AAA group, with 52.2% hospital morbidity.
- The 3-year actuarial survival rate was 84.9%.
- Intraoperative myocardial infarction occurred in one patient in the AOD group.
Conclusions:
- Combined CABG and abdominal aortic surgery is a reasonable option for selected patients with severe CAD and symptomatic abdominal aortic disease.
- Maintaining partial CPB during aortic surgery may protect the ventricle from infrarenal aortic clamping effects.
- This approach can be safely performed in patients unsuitable for staged procedures.
Abstract:
In patients with severe coronary artery disease (CAD) abdominal aortic surgery is still associated with high morbidity and mortality rates. Some patients will present with both symptomatic CAD and large, symptomatic abdominal aortic aneurysms (AAA) or end-stage aortic occlusive disease (AOD) that does not allow for a two-stage procedure. We report a series of 29 patients who underwent simultaneous coronary artery bypass graft surgery (CABG) and abdominal aortic surgery (25 AAA, 4 AOD). In the AAA group there were 23 males and 2 females with a mean age of 68 years (50-80). Sixteen patients presented with severe three-vessel disease. Ten patients had unstable angina. Aortic stenosis or insufficiency was present in two and one patient, respectively. Four patients with three-vessel disease and an ejection fraction below 30% presented with end-stage AOD and critical limb ischemia. Coronary bypass graft surgery was performed first. With the patient still on partial cardiopulmonary bypass, abdominal aortic surgery was carried out. Patients received an average of 3.1 coronary bypass grafts. Additionally, three aortic valves were implanted. Fourteen tube grafts and 15 bi-iliacal or bifemoral bifurcation grafts were placed in the abdominal aortic position. Additional vascular surgery was performed in five patients. Intraoperative management was without complication in all but one patient, who had intraoperative myocardial infarction (AOD group). Hospital mortality was 8% (2/25) in the AAA group. There was however substantial hospital morbidity (52.2%). The mean follow-up is 20.5 +/- 2.5 months. The actuarial survival rate at 3 years is 84.9%. It is concluded that combined CABG and abdominal aortic surgery is a reasonable option for patients who present with both severe CAD and symptomatic abdominal aortic disease. The continuation of CPB during aortic surgery may effectively prevent the adverse effects of infrarenal aortic clamping on a failing ventricle.