Results from coronary artery bypass surgery combined abdominal aortic aneurysm repair

Combined Coronary Artery Bypass Grafting and Abdominal Aortic Aneurysm Repair: Presentation of 3 Cases and a Review of the Literature

BACKGROUND

Coronary artery disease and abdominal aortic aneurysmal disease can occur in a single patient, and a therapeutic conundrum presents when open surgical repair is indicated for both conditions. The traditional standard of care is to conduct coronary artery bypass grafting (CABG) followed by abdominal aortic aneurysm (AAA) repair 2-6 months later, but there is significant risk with staging these 2 major surgeries. An alternative method is to surgically repair both diseases in 1 combined operation. The aim of our study is to review our own experience with the combined procedure and to review the published literature to assess morbidity and mortality of combined CABG and AAA repair.

METHODS

A systematic search for relevant studies was performed in the PubMed/Medline database. Short-term mortality (<30 days) and postoperative complications were assessed from relevant case series from 1993 to 2013. We also conducted a retrospective chart review of all patients undergoing the combined procedure at our institution.

RESULTS

Thirty case series with a total of 369 patients averaged a 30-day mortality of 3.0%. Fourteen percent and 6% of patients experienced a cardiovascular or respiratory complication, respectively. Other postoperative events included acute renal failure (7%) and superficial wound complications (5%). In our own experience, 3 patients underwent combined CABG and AAA repair. The mean age was 71 years, the average AAA size was 8.9 cm, and average operative time was 328 min. None experienced any postoperative complications. Two are still alive at 9 and 10 years after surgery, and 1 died of unrelated causes 8 years postoperatively.

CONCLUSIONS

The results of this systematic review suggest that combined CABG and AAA repair is a viable procedure with low operative mortality. Patients with preserved ejection fractions, large AAA, and limited comorbidities appear to receive the most benefit from a combined approach based on reported data from the literature. We have experienced promising results in our highly selected patient population. More research is warranted to devise criteria to determine which patients would be good surgical candidates for this combined procedure.

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.

Aortic stent-grafting: successful introduction into the combined procedure for coronary artery bypass grafting and aortic aneurysm repair

OBJECTIVES

Coronary artery bypass grafting (CABG) and combined stent-grafting (SG) were evaluated to reduce morbidity and mortality of patients with descending or infrarenal aortic aneurysm.

METHODS

CABG and SG (thoracic n=6, infrarenal n=36) were performed during the same hospitalization in 42 patients (mean age of 73+/-14 years). In 29 patients (mean Euroscore: 9), SG was performed under local anesthesia 9+/-3 days after coronary surgery (simultaneous) and in 13 patients (mean Euroscore: 7) during the same anesthesia (synchronous). In the latter group, 11 out of 13 patients underwent off-pump CABG. All aneurysms were treated by implantation of commercially available self-expanding grafts.

RESULTS

CABG was successful in all, but one patient with left internal mammary artery hypoperfusion syndrome, requiring an additional distal saphenous graft to the left anterior descending coronary artery. SG was uneventful in 98% (41/42 patients). Postoperative computerized tomography showed incomplete sealing in seven patients (17%), but only the two attachment endoleaks had to be treated by one proximal and one distal SG extension. Overall hospital stay for the synchronous repair was 12.5+/-6 days and that of the simultaneous group 17.5+/-7 days. Thirty-day mortality was 5% (2/42) as one patient of the simultaneous group experienced a lethal cerebral embolism during SG and one patient of the synchronous group developed an untreatable infection. In the follow-up of 4 years, there were two vascular reinterventions but no additional procedure-related morbidity or mortality.

CONCLUSIONS

This experience shows that combined CABG and SG of thoracic or infrarenal aortic aneurysm is a safe and less-invasive alternative to the open graft repair, especially in the older patients or patients with severe comorbidities.

Combined off-pump coronary artery bypass and abdominal aortic surgery is associated with low morbidity and mortality

Patients with abdominal aortic aneurysms (AAAs) often have concomitant coronary artery disease. In patients with large or symptomatic AAAs and symptomatic coronary artery disease, it may be necessary to address both problems simultaneously. We report a case series of five patients undergoing simultaneous off-pump coronary artery bypass and abdominal aortic reconstruction. Our series and a literature review indicate that simultaneous coronary artery bypass grafting on the beating heart and abdominal aortic surgery is safe and effective and has a low perioperative morbidity rate.

Combined 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). Eleven patients underwent the combined operation of coronary artery bypass grafting (CABG) on the beating heart and AAA repair: 10 underwent off pump CABG and 1 patient required centrifugal pump and pulmonary assist with closed circuit because of unstable hemodynamics. All cases were discharged without severe complications and with patent coronary bypass grafts.