Surgical approach to combined coronary revascularization and abdominal aortic aneurysmectomy

Combined repair of peripheral vascular disease and myocardial revascularization has become accepted treatment in selected patients. Two of our patients underwent such a procedure. One patient suffered an intraoperative dissection of the ascending aorta following myocardial revascularization. Ascending aortic replacement and vein graft reimplantation was accomplished as well as repair of the abdominal aortic aneurysm. Because of this experience we recommend that following myocardial revascularization, aortic cannulation be maintained during repair of the abdominal aortic aneurysm. This allows immediate access to cardiopulmonary bypass should untoward cardiovascular events occur during aneurysm repair.     

Role of coronary angiography and coronary artery bypass surgery prior to abdominal aortic aneurysmectomy

It is well recognized that patients with abdominal aortic aneurysms have a high incidence of coronary artery disease, and that the major cause of death in patients undergoing aneurysmectomy has been acute myocardial infarction. In order to assess the incidence of significant coronary artery disease, cardiac catheterization was performed on 42 consecutive patients with abdominal aortic aneurysms. Thirty-six patients (85.7%) had significant anatomic coronary artery disease. Interestingly, all 8 patients with ejection fractions of less than 50% had triple vessel disease or left main disease, and 12 of 34 patients with ejection fractions greater than or equal to 50% had triple vessel disease or left main disease. Of the 30 patients who were NYHA Class I or Class II, 14 (46.7%) had triple vessel disease or left main disease. All 20 patients with triple vessel disease or left main disease underwent myocardial revascularization 7 to 10 days prior to abdominal aneurysmectomy. No patients had a perioperative myocardial infarction either following coronary artery bypass surgery or abdominal aortic aneurysm resection, and there were no operative mortalities. Although this was not a randomized study, it would seem from these results that in selected patients, myocardial revascularization prior to abdominal aneurysmectomy can decrease the incidence of acute myocardial infarction and also decrease operative mortality. It is presently recommended that all symptomatic patients, patients with ejection fractions of less than 50%, and asymptomatic patients with ejection fractions of greater than or equal to 50% with positive exercise radionuclide angiography undergo cardiac catheterization prior to aneurysmectomy, and those patients with left main disease or severe coronary artery disease undergo myocardial revascularization prior to aneurysm resection.     

Simultaneous operation of off pump coronary artery bypass and abdominal aortic aneurysm repair

Objectives: Coronary artery disease (CAD) and abdominal aortic aneurysms (AAA) commonly coexist. However, each disease treatment complicates the management of the other. In this study, we evaluate whether a simultaneous operation of AAA repair and off pump coronary artery bypass (OPCAB) would be safe and acceptable, compared with either procedure alone. Subjects and Methods: We retrospectively reviewed all patients who underwent simultaneous AAA repair and OPCAB (AAA/OPCAB, n=18), compared AAA repair alone (AAA, n=239) and OPCAB alone (OPCAB, n=137) from June 1999 to December 2003. There were no significant differences with regard to age or gender, but the AAA/OPCAB group had significantly larger aneurysms (60.6 vs. 53.2 mm) and significantly lower ejection fractions (EF) (54.9 vs. 60.3%). Results: The patients in the AAA/OPCAB group underwent a significantly longer operative time than AAA, OPCAB (403 vs. 360,296 minutes, respectively), there was significantly greater blood loss (726 vs. 426, 462 ml), and more transfusion required (8.13 vs. 1.69, 2.8 units). The number of bypass grafts in AAA/OPCAB group (1–5 per patients) was significantly smaller (1.78 vs. 2.93). The AAA/OPCAB patients had a significantly longer hospital stay than the AAA (38 vs. 22 days), but was not significantly longer than the OPCAB. There were no significant differences with regard to the morbidity and mortality rate among the three groups. Conclusion: This study suggests that the simultaneous operation of AAA and OPCAB can be done with the same morbidity and mortality as independent surgical procedures. Key words: coronary artery bypass grafting, abdominal aortic aneurysm, off pump coronary artery bypass, simultaneous operation     

Combined abdominal aortic aneurysmectomy and other abdominal operations.

BACKGROUND AND AIM: Co-existence of intra-abdominal non-vascular disease with an abdominal aortic aneurysm (AAA) poses a difficult surgical challenge. MATERIAL AND METHODS: Review of hospital records of 602 patients undergoing elective surgery for AAA during a 9-year period identified 61 (10.3%) patients with a co-existent intra-abdominal non-vascular disease requiring surgery. RESULTS: The concomitant operations were 26 cholecystectomies, 11 inguinal hernia repairs, 2 small bowel resections, 5 left and 5 right hemicolectomies and 1 low anterior resection for colorectal carcinoma, 1 gastrectomy for gastric carcinoma, 5 nephrectomies, one salvage cystectomy for renal carcinoma and 1 left liver lobectomy for hepatrocellular carcinoma. Additional procedures for benign diseases prolonged the operative time by a mean of 35 (range 20-105) minutes and the major operations for malignancy by 120 (range 60-225) minutes. The overall hospital mortality and morbidity rates in the whole series of AAA (n = 602) remained as low as 0.66% and 13.6% respectively. There was no mortality and only two complications occurred in patients undergoing the combined procedure (n = 61). During a follow up period of 4-70 months, no graft infections were detected. CONCLUSION: In selected patients, the one stage approach is safe and effective. Attention should be given to the technical details and the rules of antisepsis. In elderly patients with AAA, a co-existent malignancy should be actively excluded.     

Results from coronary artery bypass surgery combined abdominal aortic aneurysm repair.

OBJECTIVE: Complication from coronary artery disease is a major cause of mortality and morbidity in patients undergoing abdominal aortic aneurysm repair. We report our results from coronary artery bypass surgery performed in combination with abdominal aortic aneurysm repair in patients with coronary artery disease and abdominal aortic aneurysm, each being an indication for an emergency operation. METHODS: Seventeen patients underwent combined coronary artery bypass surgery and abdominal aortic aneurysm repair. The mean age of the patients was 67.6 +/- 5.2 years. Four had left main disease, 8 patients had triple-vessel disease, and 12 had a prior myocardial infarction. The average left ventricular ejection fraction was 0.49 +/- 0.13. The average abdominal aortic aneurysm diameter was 6.2 +/- 1.0 cm (range 4.5-8.0 cm). Thirteen patients underwent coronary artery bypass surgery followed by abdominal aortic aneurysm repair after discontinuation of cardiopulmonary bypass. In the remaining four patients, including one patient with severe left ventricular dysfunction, cardiopulmonary bypass was continued as a circulatory assist until the abdominal aortic aneurysm repair was completed. The left internal thoracic artery was used in 14 patients, and the right internal thoracic artery in one patient. RESULTS: Postoperative surgical complications occurred in three patients (bleeding in one patient requiring reoperation, abdominal subcutaneous wound infection in another and transient neural disorder in the others). There were no surgical or in-hospital death. There was no late cardiac complication and no late cardiac death after a mean of 29 months follow-up. CONCLUSIONS: We concluded that combined surgery was reasonable for selected patients with combined coronary artery disease and abdominal aortic aneurysm, each of which is an indication for an urgent operation. The aortic aneurysm repair during cardiopulmonary bypass for patients with severe left ventricular dysfunction was safe and effective.     

Simultaneous operation for minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair

Simultaneous minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair were conducted in a 66-year-old man uneventful, requiring no transfusion. Surgery required 9 hours and 2 minutes. The tracheal tube was extubated in the operating room. Postoperative bleeding was 215 ml. The postoperative course was very smooth, with the patient able to walk on postoperative day 1. Postoperative coronary arteriogram and aortogram showed favorable results and the patient was discharged on day 23 after surgery.     

Minimally invasive direct coronary artery bypass combined with abdominal aortic aneurysm repair.

BACKGROUND: For simultaneously combined coronary artery bypass surgery with infrarenal abdominal aortic aneurysm (AAA) repair, a relatively high operative mortality and morbidity have been reported. METHODS: From February 1998 to December 1998, simultaneous minimally invasive direct coronary artery bypass combined with the AAA repair was performed for 4 patients (3 males, 1 female; mean age, 74+/-7 years). Three were high-risk patients: 2 were over 75 years of age, 2 had respiratory insufficiency, and 1 had severe renal impairment. RESULTS: There were no mortalities. The endotracheal tube was removed within approximately 12 hours, and the postoperative courses were uneventful. During 4+/-4 months of follow-up, there was neither angina recurrence nor other morbidity. CONCLUSIONS: Minimally invasive direct coronary artery bypass combined with AAA repair was safe even for high-risk patients.     

Simultaneous operation for minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair.

Simultaneous minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair were conducted in a 66-year-old man uneventful, requiring no transfusion. Surgery required 9 hours and 2 minutes. The tracheal tube was extubated in the operating room. Postoperative bleeding was 215 ml. The postoperative course was very smooth, with the patient able to walk on postoperative day 1. Postoperative coronary arteriogram and aortogram showed favorable results and the patient was discharged on day 23 after surgery.     

Efficacy of bispectral index for anesthetic management of combined off-pump coronary artery bypass grafting and abdominal aortic aneurysm replacement]

A 57-year-old female patient underwent combined off-pump coronary artery bypass grafting and abdominal aortic aneurysm replacement. Anesthesia was maintained with propofol, fentanyl, and thoracic epidural anesthesia. Propofol doses were adjusted to maintain bispectral index (BIS) between 40-60. Despite the remarkable hemodynamic changes, BIS remained stable at about 50 during the surgery. The average dose of propofol was 3.3 mg.kg-1.hr-1. The patient awoke an hour after the surgery and was extubated 1.5 hours thereafter. This case report suggests that BIS is a useful index to determine the depth of anesthesia during surgeries which induce marked hemodynamic changes.     

One-stage coronary and abdominal aortic operation with or without cardiopulmonary bypass: early and midterm follow-up

BACKGROUND: The aim of this study was to compare hospital, early, and late clinical outcomes for patients undergoing one-stage, coronary and abdominal aortic surgical intervention with and without cardiopulmonary bypass. METHODS: From March 1990 to September 1999, 42 consecutive patients underwent combined operations at a single institution. Cardiopulmonary bypass and cardioplegic arrest were used during coronary revascularization in the first 20 patients (on-pump group), and the next 22 patients received the one-stage operations on the beating heart (off-pump group). RESULTS: Baseline characteristics were similar between groups. Three cardiac-related hospital deaths occurred in the on-pump group and one such death in the off-pump group (p = 0.25). Cardiac-related events, pulmonary complications, inotropic support, blood loss and transfusion requirements, intensive care unit stay, and hospital stay were significantly reduced in the off-pump group (all, p < 0.05). The actuarial survival rates in the on-pump and off-pump groups were 80% and 95%, respectively, at 1 year (p = 0.13) and 75% and 89%, respectively, at 3 years (p = 0.22). Freedom from cardiac-related events at 1-year follow-up was 91% in the off-pump group and 65% in the on-pump group (p < 0.05). No difference in cardiac-related events between groups was observed at 3 years. CONCLUSIONS: Off-pump coronary surgical procedures decrease postoperative complications in high-risk patients undergoing simultaneous coronary and abdominal aortic operations compared with the conventional one-stage procedure. The early benefits achieved with off-pump surgical intervention are not at the expense of the long-term clinical outcome.     

Results of combined left ventricular aneurysmectomy and coronary artery bypass: 1974 to 1980

Left ventricular aneurysm repair with coronary artery bypass grafting was performed in 104 patients from 1974 through 1980. The patients' mean age was 57 years. Preoperatively, 48 percent were in New York Heart Association functional class III and 31 percent were in class IV. Stenosis of multiple vessels was common, as was a reduced ejection fraction (24 percent had an ejection fraction of less than 30 percent) Thrombus was present in 47 percent of resected aneurysms. Bypass grafting was performed to all graftable coronary vessels. Actuarial survival rates were 89.3 percent at 1 year, 86.1 percent at 2 years, and 74.5 percent (standard error 5.1 percent) at 5 years. One year postoperatively, 86 percent of the surviving patients were in class I, 11 percent class II, 1 percent class III, and 2 percent class IV. Patients who presented with angina alone had an excellent result, with 96 percent hospital survival. Congestive heart failure was an ominous finding, since four of five patients who developed it before discharge died in the hospital, and 38 percent of those who went into heart failure after discharge have died.     

Routine aortography before abdominal aortic aneurysmectomy: A prospective study

Routine preoperative arteriography was studied prospectively in 104 patients with abdominal aortic aneurysms. The patients were from the private practice of 11 vascular surgeons. Information regarding patient clinical status was gathered and compared with aortographic and intraoperative findings. Special attention was focused on the question of operation modification as dictated by aortographic findings. The surgeons were further asked whether the information gained from surgical exploration was equal to that obtained from arteriography. It is concluded that because of low yield of benefit, economic considerations, time delay, and minor but distinct risks of the procedure, arteriography should be used selectively rather than routinely in such patients.     

Successful simultaneous renal transplantation and abdominal aortic aneurysmectomy.

At the time of related donor renal transplantation, a 49-year-old man with chronic glomerulinephritis was found to have a large fusiform aneurysm involving the internal and external iliac arteries, the abdominal aorta, and both common iliac arteries. Transplantation and abdominal aneurysmectomy using a standard Dacron bifurcation graft were successfully carried out. This patient has had no associated complications and is currently five years after transplantation and aneurysmectomy, with excellent renal function. It is believed that transplantation may now be offered to an older age group of patients with end-stage renal disease in whom atherosclerosis wll have developed as a natural process of aging.     

Mid-term results of combined transmyocardial laser revascularization and coronary artery bypass

BACKGROUND: Transmyocardial laser revascularization is increasingly used to treat intractable angina in the absence of graftable vessels; however, its role in combination with coronary artery bypass grafting remains undefined. The aim of this pilot study was to investigate the outcome of the combination therapy at mid-term follow-up. METHODS: Patients (n = 20) who had elective coronary artery bypass with one or more nongraftable coronary arteries were prospectively randomized to have either coronary artery bypass grafting alone or combination coronary artery bypass grafting plus transmyocardial laser revascularization with a holmium:YAG (yttrium-aluminum-garnet) laser to nongraftable areas. All patients had an exercise tolerance test preoperatively and at 6, 18, and 36 months follow-up. Stress echocardiography was performed on 17 patients at 18 months postoperatively, and regional wall motion score index was calculated in lased and nonlased nonrevascularizable myocardium of the left ventricle at rest and with dobutamine stress. RESULTS: Both groups of patients were similar in preoperative demographics and operative data. There was no perioperative death. There was no difference between the two groups in angina scoring at 6, 18, and 36 months follow-up. Exercise tolerance improved by a mean of 46.8 +/- 20.0 seconds in the coronary artery bypass grafting group versus 199.2 +/- 66.5 seconds per patient in the coronary artery bypass grafting plus transmyocardial laser revascularization group (p = 1.8 x10(-6)) at 6 months; this benefit was maintained at 18 months (157 +/- 46.3 versus 61 +/- 39.2 seconds; p = 4 x10(-4)) but was lost at 36 months (57.2. +/- 42.1 versus 68.1 +/- 46.7 seconds; p = 0.70). The mean values for wall motion score index in the lased and nonlased regions at each stage of dobutamine stress at 18 months after surgery were not statistically significant. CONCLUSIONS: The combination of coronary artery bypass and transmyocardial laser revascularization improved exercise tolerance in patients in whom complete revascularization could not be achieved by bypass grafting alone in the short term, but this benefit was lost by 36 months postoperatively. The transient improvement in exercise tolerance cannot be explained by changes in contractility in the lased areas.     

Two cases of off-pump coronary artery bypass grafting combined with abdominal aortic aneurysm repair.

Two cases of coronary artery disease coexisting with abdominal aortic aneurysm were treated with off-pump coronary artery bypass grafting combined with repair of the aneurysm. The first patient was a 67-year-old man exhibiting a large pulsating abdominal mass. Abdominal computed tomography demonstrated a 9-cm aneurysm and coronary angiogram revealed a 90% stenosis of the obtuse marginal branch for which percutaneous transluminal angioplasty could not be performed. He underwent simultaneous single coronary artery bypass grafting without cardiopulmonary bypass, and bifurcated graft replacement. The second patient was a 71-year-old man who had acute myocardial infarction, and one month later underwent coronary angiogram which revealed three vessel disease in the coronary artery. Computed tomography revealed a 4-cm aneurysm, and angiography showed a 90% stenosis of the left renal artery. He underwent a single stage operation that involved three coronary artery bypass grafting without cardiopulmonary bypass, straight graft replacement, and reconstruction of the left renal artery using the saphenous vein graft. The postoperative course was uneventful in both cases. We currently recommend a single stage operation involving off-pump coronary artery bypass grafting.     

A simultaneous operation of A-C bypass and replacement of abdominal aortic aneurysm--a successful case

A 70-year-old man was successfully operated on A-C bypass for coronary triple vessel disease and replacement of abdominal aortic aneurysm. The two different procedures were performed simultaneously under cardio-pulmonary bypass. This simultaneous operation can provide benefits of shortening operating time and of clamping easily the abdominal aorta.