For debate: concomitant critical coronary arterial disease and abdominal aortic aneurysm--timing of corrective procedures

BACKGROUND: The high prevalence of coronary artery disease (CAD) in patients with abdominal aortic aneurysm (AAA) is responsible for most , 30-day mortality and morbidity in elective repair of AAA. The continuing debate regarding staged or combined surgery for AAA and CAD (coronary artery bypass grafting -CABG) in the small number of patients with critical degrees of both co-morbidities has not had a significant impact on the greater mortality and morbidity when the AAA repair is undertaken using the standard open operation. PATIENTS: We report four cases with these combined pathologies which we have managed over the last 30 months during which time we have developed techniques of endolumenal repair of AAA. CONCLUSIONS: Whilst it is not possible to make firm recommendations regarding management strategy owing mainly to a lack of large series reporting this unusual combination of co-morbidities, the options are debated on the basis of published anecdotal evidence as well as our own case reports. We suggest that if the AAA is non-tender and/or 5.5-8.0 cm, the staged approach is appropriate. If the AAA is tender and/or > 8.0 cm, a combined approach may be a better option in order to avoid the risk of AAA rupture during the interval between the operations. Endolumenal repair of AAA offers a further option for the staged and combined approach, and may be less invasive than the standard open surgery for AAA repair.     

Simultaneous endovascular aortic aneurysm repair and coronary artery bypass grafting in a patient with abdominal aortic aneurysm and left main trunk lesion

To patients with severe coronary artery disease (CAD) and expanding large abdominal aortic aneurysm (AAA), simultaneous coronary artery bypass grafting (CABG) and AAA repair has been recommended. A 68-year-old woman had a CAD and an AAA 71 mm in diameter which was enlarging. Coronary angiography showed severe stenoses in the left main trunk (LMT), the left anterior descending artery and the circumflex artery. On-pump beating CABG and AAA repair with endovascular aneurysm repair (EVAR) were performed simultaneously, because intraaortic balloon pumping (IABP) might be needed due to severe stenoses of LMT. Just after EAVR, on-pump beating CABG was performed. The patient was discharged 15 days after the operation. It was suggested that a simultaneous operation of CABG and EVAR might be safe and effective for high risk patients with CAD and AAA.     

Combined Abdominal Aortic Aneurysm Repair and Coronary Artery Bypass: Presentation of 13 Cases and Review of the Literature

Coronary artery disease remains the major cause of perioperative mortality after abdominal aortic aneurysm (AAA) repair. The beneficial effect of coronary artery bypass (CAB) before AAA repair in patients with severe coronary artery disease has been proven. The coexistence of a very large or symptomatic AAA and coronary artery disease remains a therapeutic challenge since there is the risk of AAA rupture in the interval between CAB and AAA repair. Combined CAB and aortic aneurysm repair has been suggested for these cases, and results on several series of patients have been published. However, the exact indication for the combined operation remains to be clarified. We present a series of 13 patients who underwent CAB on cardiopulmonary bypass and aortic aneurysm repair as a one-stage procedure. The indication was a large AAA in seven patients and a symptomatic AAA in six patients. In four patients, the aortic reconstruction was performed without the use of cardiopulmonary bypass; in nine patients, the aortic reconstruction was performed under partial cardiopulmonary bypass. Thirty-day mortality was 15%. Major morbidity was 31%. All major complications were due to excessive bleeding and occurred in patients who had AAA repair performed with partial cardiopulmonary bypass, suggesting that prolonged bypass time represents a major source of morbidity. A detailed review of the literature is presented. From the evidence available we suggest that the combined procedure can be recommended only for patients with very high rupture risk, such as in symptomatic AAA. In all other cases, the staged approach — CAB followed by AAA repair 2-4 weeks later — is preferable. During the combined procedure, cardiopulmonary bypass support during AAA repair should be used only in patients with clear evidence of hemodynamic instability.     

Coronary artery disease in patients requiring abdominal aortic aneurysm repair. Selective use of a combined operation.

The chief cause of operative mortality after abdominal aortic aneurysm (AAA) repair is myocardial infarction. For this reason, routine coronary angiography followed by prophylactic coronary artery bypass grafting (CABG) prior to AAA repair has been recommended by some surgeons. We report here the results of the selective use of a combined operation. Two hundred twenty-seven patients had elective or emergency repair of nonruptured AAA on our service from 1972 to 1983. Prior to surgery, all patients underwent careful clinical evaluation for the presence of coronary artery disease (CAD) and were classified into the following: group I (n = 121), no clinical evidence of CAD, 53%; group II (n = 96), clinical evidence of stable CAD, symptomatic or asymptomatic, 42%; group III (n = 10), unstable CAD, five per cent; Group IIIa (n = 4), asymptomatic AAA; and group IIIb (n = 6), symptomatic AAA. Seven patients ultimately assigned to group II underwent stress electrocardiogram (ECG) and eight group II patients had coronary angiography before surgery. All patients in groups I and II underwent elective or urgent repair of their AAA without CABG. Prior to surgery, these patients were managed with placement of a pulmonary artery catheter and incremental volume loading to construct a left ventricular performance curve as a guide to surgical fluid replacement. All were carefully monitored for at least 48 hours after surgery in an intensive care unit. Four patients (group IIIa) with unstable CAD and asymptomatic AAA underwent CABG followed by elective AAA repair within six months. Six patients (group IIIb) with unstable CAD and symptomatic AAA underwent combined open heart surgery (CABG and, in one patient, valve replacement) and AAA repair as a single operation. There was no operative mortality in group III patients. Thirty-day operative mortality for the entire group of 227 patients was 1.3% (three deaths), with only one death from a myocardial infarction (0.4%). While there is clearly a high incidence of CAD in patients with AAA, the present results indicate that these individuals can be managed with low risk by a selective approach based upon clinical assessment of their CAD. Our experience further demonstrates that patients with unstable CAD and symptomatic AAA may have both lesions safely repaired as a single operative procedure.     

Usefulness of one-stage coronary artery bypass grafting on the beating heart and abdominal aortic aneurysm repair.

Abdominal aortic aneurysm (AAA) is commonly associated with coronary artery disease (CAD). Simultaneous coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) under cardiac arrest and AAA repair may be considerably invasive. Recently CABG under the beating heart without CPB has been reported as a less invasive method. We report the combined operation of CABG on a beating heart and AAA repair for AAA patients with CAD, and compare it with a separate operation. A retrospective review of the records of consecutive patients who underwent elective combined procedure or single operation for CABG on a beating heart and/or repair of the AAA between May 1999 and October 2001 was carried out. Ten patients underwent combined procedures. A single operation, CABG on a beating heart or repair of AAA, were performed in 27 or 19 patients. There were no significant differences with regard to intraoperative blood loss, transfusion and postoperative intubation time among the three groups. There was no operative mortality for any of the three groups. All cases were discharged without severe complications and with patent coronary bypass grafts. There was a decrease in mean total hospital costs for the combined operation group compared with the CABG group plus AAA repair group (3.34 million versus 5.87 million yen). Combined CABG on a beating heart and AAA repair on a one-step approach appears to be a safe and useful therapeutic strategy for AAA patients with CAD.     

Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization.

OBJECTIVE: The authors ascertained the optimal timing of repair of an abdominal aortic aneurysm (AAA) after coronary artery revascularization. SUMMARY BACKGROUND DATA: Cardiac events are the most common cause of death after elective repair of AAA. Preoperative coronary revascularization has significantly reduced postoperative cardiac complications after elective AAA repair. Currently, most patients undergo repair of asymptomatic AAA within 6 months after the coronary revascularization. METHODS: The authors performed a retrospective review of patients who underwent repair or scheduled repair of an asymptomatic AAA within 6 months after coronary artery bypass graft (CABG) between March 1988 and October 1993. RESULTS: There was no mortality in the group of patients (n = 14) who underwent repair of AAA simultaneously or within 14 days of coronary revascularization. In contrast, there was a significantly increased mortality rate of 3 of 9 (33%) in patients scheduled to undergo repair of the AAA more than 2 weeks after coronary revascularization (p < 0.05). All nonsurvivors died between 16 and 29 days after CABG, and died as a result of ruptured AAA. CONCLUSION: Elective AAA repair should be undertaken simultaneously or within 2 weeks of coronary artery revascularization because of an increased risk of postoperative AAA rupture seen after this time period. In addition, simultaneous or early postoperative AAA repair does not increase the overall operative risk.     

Influence of Coronary Artery Disease on Operative Mortality and Long-Term Survival After Abdominal Aortic Aneurysm Repair

Purpose This retrospective study was conducted to evaluate the effects of coronary artery disease (CAD) on short- and long-term survival after abdominal aortic aneurysm (AAA) repair.Methods One hundred consecutive patients underwent elective AAA repair between 1991 and 2002. Coronary angiography was performed in all patients, revealing significant coronary artery lesions in 47 (47%). Percutaneous transluminal coronary angioplasty (PTCA) was performed in 11 patients, 20 (median) days before the abdominal surgery. Abdominal aortic aneurysm repair was performed 60 (median) days after coronary artery bypass grafting (CABG) in five patients, and both procedures were performed simultaneously in two patients.Results The in-hospital mortality rate for AAA repair was 1.0%, but there was no cardiac-related operative morbidity or mortality. The 96 patients discharged were followed up for a mean period of 2.9 years (range 3–143 months). The cumulative survival rates after 1, 2, 3, and 5 years were 98%, 95%, 88%, and 77%, respectively. Only one patient (1%) died of myocardial infarction. There was no significant difference in the long-term survival of the CAD and non-CAD patients.Conclusions These results emphasize the importance of routine coronary angiography and subsequent coronary revascularization to improve early and late survival rates after AAA repair.     

Temporary axillo-femoral bypass for abdominal aortic aneurysm repair in high risk patients.

Abdominal aortic aneurysm (AAA) is sometimes associated with coronary artery and valvular disease. We report the successful treatment of a 76-year-old woman diagnosed with an infrarenal AAA, associated with severe mitral regurgitation and double-vessel coronary artery disease. First, AAA repair, using temporary axillo-femoral bypasses on both sides was done. Second, after 77 days, we simultaneously undertook coronary artery bypass grafting (CABG) and mitral valve repair. This staged operation achieved an excellent result. This rarely used abdominal aortic surgical procedure contributed to minimizing variations in afterload, an important consideration in high risk cardiac patients.     

Coronary artery bypass surgery in patients with abdominal aortic aneurysm: detection and treatment of concomitant coronary artery disease.

OBJECTIVES: Complication due to coronary artery disease (CAD) is a major cause of mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The purpose was to show 1) the incidence of patients who required coronary artery bypass grafting (CABG), and 2) risk factors for the necessity of CABG in patients with AAA. METHODS: Subjects were consecutive 159 patients (132 males and 27 females) undergoing elective repair of non-ruptured AAA between May 1993 and March 2002. Most patients (n=145) underwent routine preoperative coronary angiography (CAG) and received coronary revascularization when necessary. Clinical atherosclerotic risk factors were subjected to univariate and multivariate analysis to determine predictors for the necessity of CABG. RESULTS: Of 43 patients (27.0%) with significant coronary stenosis, 7 patients (4.4%) underwent CABG concomitantly (n=1) or prior to the AAA repair (n=6) in the same admission. Other patients received percutaneous transluminal coronary angioplasty (PTCA) (n=14) and isolated medical treatment (n=22). Overall mortality of 159 patients undergoing AAA repair was 2.5% and there were no deaths in 7 patients undergoing CABG. Univariate and multivariate analysis indicated only the history of angina as significant for the necessity of CABG in patients with AAA. Of 155 survivors, 5 patients underwent CABG later in the follow-up period. CONCLUSIONS: The incidence of patients who required CABG in the treatment of AAA was 4.4% in our institute. It was difficult to predict the necessity of CABG without conducting CAG in patients with asymptomatic myocardial ischemia. These results may justify the routine enforcement of preoperative CAG in patients with AAA.     

Simultaneous coronary bypass and abdominal aortic surgery in patients with severe coronary disease — indication and results

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.     

The intra-aortic balloon pump,a novel addition to staged repair of combined symptomatic cerebrovascular and coronary artery disease

Five patients with severe symptomatic carotid and coronary artery disease were treated with staged carotid endarterectomy and coronary artery bypass grafting (CABG) under the protection of an intra-aortic balloon pump (IABP) over a 56-month period. All patients presented with unstable angina and multiple ipsilateral transient ischemic attacks. Two of the four patients had four previous myocardial infarctions. Arteriography demonstrated three-vessel coronary artery disease and 80% to 95% stenosis of the ipsilateral internal carotid artery in all patients. An IABP was placed prior to uneventful carotid endarterectomy performed with vein patch angioplasty (three patients) or primary closure (two patients) under general anesthesia. All five patients had remarkably stable blood pressure and cardiac outputs while on the IABP. Twenty-four hours after carotid endarterectomy the patients underwent uneventful CABG of three or more vessels. No complications occurred with either surgical procedure. One patient required femoral embolectomy and repair of a small false femoral aneurysm following removal of the IABP. All patients were discharged home 7 to 13 days after CABG. This initial report suggests that IABP can be used safely in staged operations for carefully selected patients with unstable angina and severe symptomatic carotid artery disease.Presented at the Sixteenth Annual Meeting of The Southern Association for Vascular Surgery, St. Thomas, Virgin Islands, January 24, 1992.     

The role of coronary artery disease in complications of abdominal aortic aneurysm surgery

Coronary artery disease (CAD) is a major cause of morbidity and mortality after elective surgical repair of abdominal aortic aneurysm (AAA). The aim of this study was to determine the relationship between the extent of CAD observed in coronary angiograms (more than 50% stenosis) and the frequency of postoperative myocardial ischemic complications in a consecutive series of 84 patients who underwent elective AAA repair. Ninety-four percent of the patients with clinical evidence of CAD had significant disease as observed in coronary angiograms and eight patients had left main CAD. Seventy-two patients underwent AAA repair with a mortality rate of 1.4%; five patients had preliminary myocardial revascularization, and AAA surgery was not recommended for four patients because of severe cardiac disease. Postoperative myocardial ischemic complications occurred in 13.4% of the patients who had undergone surgery--almost exclusively in patients with clinical evidence of CAD. Both myocardial ischemia and preoperative intervention were more frequent in patients with double- or triple-vessel disease than in patients with less extensive disease. Patients with symptoms and with double- or triple-vessel CAD have a high risk of developing myocardial ischemia after AAA surgery. Preliminary myocardial revascularization may be beneficial in this group of patients.     

Postoperative rupture of abdominal aortic aneurysm in patients with ischemic heart disease and other organ disease

We experienced two cases of rupture of an abdominal aortic aneurysm during the early postoperative period of coronary artery bypass grafting (CABG). A 71-year-old man on hemodialysis (HD) was diagnosed with ischemic heart disease (IHD) and abdominal aortic aneurysm (AAA) of 70 mm in size. After CABG, he developed symptoms of acute pancreatitis and died of rupture of AAA on the 12th postoperative day. A 74-year-old man with early gastric cancer was diagnosed with IHD and AAA of 70 mm. After CABG and gastrectomy, he died of rupture of AAA due to anticoagulant therapy on the 3rd postoperative day. One-stage operation should be performed in patients with IHD, AAA more than 60 mm in size and other organ disease. It is important to control blood pressure and anticoagulant therapy appropriately during the early postoperative period when graft replacement for AAA is not performed simultaneously. Careful observation is required to establish the differential diagnosis of acute pancreatitis and impending rupture of AAA in patients on HD.     

Late results of coronary bypass in patients with infrarenal aortic aneurysms. The Cleveland Clinic Study.

Cardiac catheterization was performed in a prospective series of 1000 patients under consideration for elective peripheral vascular reconstruction at the Cleveland Clinic from 1978-1982. Of these, 246 patients (mean age: 68 years) presented primarily because of infrarenal abdominal aortic aneurysms (AAA) and are eligible for subsequent evaluation 3-7 years (mean: 4.6 years) after entrance into the study. Severe, surgically correctable coronary artery disease (CAD) was documented in 78 patients (32%) in the AAA group, and 70 patients (28%) received myocardial revascularization with four fatal complications (5.7%). A total of 56 patients in this subset had staged aneurysm resection, usually during the same hospital admission after coronary bypass, with a single death (1.8%) caused by cerebral infarction. The overall operative mortality rate for 126 coronary and AAA procedures was 4%. A total of 59 additional patients (25%) died during the late follow-up interval, including 14 patients (5.9%) with cardiac events and eight patients (3.4%) with ruptured aneurysms. The cumulative 5-year survival rate (75%) and cardiac mortality rate (5%) after coronary bypass reflected traditional parameters (preoperative ventricular function, completeness of revascularization) and are nearly identical to the results calculated for patients having normal coronary arteries or only mild to moderate CAD. In comparison, the cumulative survival and cardiac mortality rates in a small subset of patients with severe, uncorrected coronary involvement currently are 29% (p = 0.0001) and 34%, respectively. These data support the conclusion that selected patients who require elective resection of AAA also warrant myocardial revascularization to enhance perioperative risk and late survival.     

Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease.

Routine coronary angiography to determine the prevalence of severe coronary artery disease (CAD) has been recommended to all patients under consideration for elective peripheral vascular reconstruction at the Cleveland (Ohio) Clinic since April 1978. Those found to have severe, correctable CAD have been advised to undergo myocardial revascularization prior to performance of elective peripheral vascular operations. Forty-one of the 68 patients with abdominal aortic aneurysms (AAA) and 26 of the 71 patients with aortoiliac occlusive arterial disease (AI) had clinical evidence of CAD; coronary angiography demonstrated severe, correctable CAD in 23 patients with AAA and in 14 patients with AI. Twenty-seven patients with AAA and 45 patients with AI had no clinical evidence of CAD; severe, correctable CAD was found in six patients with AAA and in six patients with AI. Ninety-six patients, including 26 who had staged cardiac procedures performed, have had elective aortic reconstruction, with one operative death.     

A personal experience with factors influencing survival after elective open repair of infrarenal aortic aneurysms

OBJECTIVE: To investigate risk factors that influence survival after open abdominal aortic aneurysm (AAA) repair in all elective patients treated by a single surgeon at a tertiary referral center. METHODS: The series includes 855 asymptomatic infrarenal AAAs in 732 men (86%) and 123 women with median ages of 69 and 71 years, respectively. Noninvasive myocardial imaging (n = 325), coronary arteriography (n = 418), or both were performed before surgery in 687 patients (80%), and 100 patients (15%) underwent preliminary coronary artery bypass grafting (n = 78) or percutaneous transluminal coronary angioplasty (n = 22) before their AAA procedures. Survival was assessed by using logistic regression analysis, proportional hazards models, and Kaplan-Meier estimations. RESULTS: The operative mortality rate was 2.5%, ranging only from 1.8% to 2.8% since 1980. Late survival rates (70% at 5 years, 36% at 10 years, and 16% at 15 years) also remained remarkably similar during five arbitrary intervals comprising the entire study period. On multivariable analysis, overall mortality rates were adversely affected by older age (P < .001), increased creatinine levels (P < .001), straight aortic replacement grafting (P < .001), larger aneurysm diameter (P = .036), and chronic obstructive pulmonary disease (P = .012). The risk for any early or late death was favorably influenced by preliminary coronary artery bypass grafting or percutaneous transluminal coronary angioplasty (hazard ratio, 0.76; 95% confidence interval, 0.59-0.98; P = .035) even when a separate multivariable model was fit to accommodate nine other patients who also had preliminary coronary intervention but developed symptomatic AAAs before elective repair could be performed (hazard ratio, 0.78; 95% confidence interval, 0.61-0.99; P = .044). CONCLUSIONS: Patient age and medical risk factors determine survival after open AAA repair to a very similar degree irrespective of the era when the operation is performed. In this particular series, preliminary coronary intervention seemed to benefit patients with severe coronary artery disease.     

Surgical stress in perioperative period of combined off-pump coronary artery bypass grafting and abdominal aortic aneurysm repair

OBJECTIVES: It is still controversial whether we should choose simultaneous operation or two-staged operation for patients who need both coronary artery bypass grafting (CABG) and abdominal aortic aneurysm (AAA) repair. Some reports suggest that combined CABG without cardiopulmonary bypass and AAA repair is less invasive than those with cardiopulmonary bypass. We estimated surgical stress of combined off pump CABG and AAA repair (CABG + AAA) in perioperative period compared with simple AAA repair retrospectively. METHODS: Seven patients (mean 60 years) underwent simultaneous operation of off pump CABG and AAA repair in our institution. We gathered data associated with circulatory, respiratory, renal function, recovery, and so on. We also examined postoperative complication and mortality. RESULTS: All parameters, except operation time and amount of catecholamine used, were not significantly different between the two groups. There were no operative mortality and only a slight morbidity in CABG + AAA. CONCLUSIONS: Our findings suggest that careful circulatory management with adequate transfusion and catecholamine use under precise monitoring is necessary during operation, but recovery after surgery, complication, and mortality in this combined operation are almost equivalent to those of simple AAA repair. We suggest that combined operation of CABG and AAA repair can be performed effectively.     

Simultaneous abdominal aortic aneurysm repair during the on-pump coronary artery bypass grafting.

A case of simultaneous coronary artery bypass grafting (CABG) and abdominal aortic aneurysm (AAA) repair on cardiopulmonary bypass (CPB) is reported. A 74-year-old man was diagnosed with left main coronary disease and infrarenal AAA. Triple CABG and infrarenal AAA repair were performed simultaneously, by different surgeons, on CPB. The duration of CPB, aortic clamp time, and total operation time was 81 min, 33 min, and 245 min, respectively. The patient was extubated three hours after ICU admission and the postoperative course was uneventful. This method is useful for reduction of operation time, for blood salvage, and for adjustment of preload and afterload of the vulnerable heart during AAA repair.     

High prevalence of unsuspected abdominal aortic aneurysms in patients hospitalised for surgical coronary revascularisation.

OBJECTIVES: Prevalence of abdominal aortic aneurysms (AAA) is not exactly known among patients with coronary artery disease (CAD) who are considered for surgical revascularisation. We evaluated the value of screening AAA among coronary patients admitted in our cardiovascular surgery unit. METHODS: Over a 24-month period, an abdominal echography was proposed to male patients aged 60 or more while hospitalised for surgical coronary revascularisation. Patients with previous investigation of the aorta were excluded. The aorta was considered aneurysmal when the anterior-posterior diameter was of 30 mm or more. RESULTS: Three hundred and ninety-five consecutive patients all accepted a proposed abdominal echographic screening for AAA. Forty unsuspected AAA were detected (10.1%). The mean diameter was 38.9 +/- 1.3 mm. Four AAA were larger than 50 mm and considered for surgery after the CABG procedure. Surveillance was proposed to the other 36, especially the 10 patients with an AAA larger than 40 mm. Patients with AAA were significantly older than those without AAA (71.3 +/- 0.8 vs. 69.4 +/- 0.3 years, P<0.05). Smoking history (P<0.05) and hypertension (P<0.05) were also associated more frequently with AAA. More than 16% of the patients being smokers and suffering hypertension presented with unsuspected AAA. CONCLUSIONS: In-hospital screening of AAA is very efficient among patients with coronary artery disease. Therefore, patients with CAD may be considered for routine AAA screening.     

Coronary artery disease in patients with abdominal aortic aneurysm

Selective coronary angiography to determine the prevalence of coronary artery disease (CAD) has been performed in patients with abdominal aortic aneurysm (AAA). Thirty patients in this series consisted of 26 men and 4 women with an age range of 48-87 years (mean +/- SD: 67.5 +/- 8.2 years). As the atherosclerotic risk factors, cigarette smoking was present in 19 patients (63.3%), hypertension was in 18 (60%), hypercholesteremia was in 10 (33.3%), and diabetes mellitus was in 2 (6.7%). Cerebral vascular disease was present in 11 patients (36.7%). Regarding CAD, angina pectoris or old myocardial infarction was found in 9 patients (30%), and abnormal electrocardiography (ECG) was in 16 patients (53.3%). Coronary angiography prior to operation of AAA was performed to 22 patients (73.3%), and 15 patients (68.2%) among them had significant coronary artery stenosis, and 9 patients underwent myocardial revascularization (4 CABG, 5 PTCA). CAD was frequently complicated both in patients without symptoms or ECG abnormalities and in less than 65-year patients. In order to prevent fatal myocardial infarction, we recommend routine coronary angiography to patients with AAA. And if necessary, myocardial revascularization must be indicated prior to aneurysmectomy.