Asian Cardiovasc Thorac Ann 2003;11:233-236
© 2003 Asia Publishing EXchange Ltd
Combined Coronary Artery Bypass Grafting and Abdominal Aortic Aneurysm Repair
Hiroshi Ohuchi, MD,
Masaaki Kato, MD,
Haruhiko Asano, MD,
Hiroaki Tanabe, MD,
Masanori Ogiwara, MD,
Kazuhito Imanaka, MD,
Satoshi Gojo, MD,
Yuji Yokote, MD,
Shunei Kyo, Md
Department of Surgery, Division of Cardiovascular Surgery, Saitama Medical School, Saitama, Japan
For reprint information contact: Hiroshi Ohuchi, MD Tel: 81 45 621 3388 Fax: 81 45 622 3389 email: hi01-oouchi{at}city.yokohama.jpDivision of Cardiovascular Surgery, Yokohama City Kowan Hospital, Yokohama, Japan.
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ABSTRACT
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The purpose of this paper was to assess the results and feasibility of simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair. Twenty nine patients with a mean age of 65 years underwent simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair between June 1990 and March 2002. All patients had significant coronary artery disease and were considered as indicated for coronary artery bypass grafting. This was performed first in 28 patients and simultaneously with abdominal aortic aneurysm repair in one, with a mean number of grafts of 2.5, a mean aortic cross-clamp time of 40 minutes, and a mean bypass time of 115 minutes. Eight straight and 21 bifurcated grafts were employed. The total operating time averaged 400 minutes. The median postoperative hospital stay was 18 days. One patient died of stroke and mediastinitis, for a mortality rate of 3.5%. This experience suggests that combined coronary artery bypass grafting and abdominal aortic aneurysm repair is both safe and effective.
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INTRODUCTION
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Almost half of patients with abdominal aortic aneurysm (AAA) have concomitant coronary artery disease (CAD). Most hospital and late deaths in patients undergoing major vascular surgery are due to cardiac accidents.1,2 In an attempt to decrease high mortality rates and to minimize the risk of myocardial infarction associated with concomitant CAD, myocardial revascularization is often performed prior to the AAA repairs.3,4 Blackbourne reported that one third of patients undergoing a staged procedure with an interval of longer than 2 weeks from coronary artery bypass grafting (CABG) died as a result of ruptured AAA. They advocated that AAA repair should be undertaken simultaneously or within 2 weeks of CABG. However, two weeks seems to be too short a recovery period for CABG patients indicated for AAA repair.5 The optimal timing for AAA surgery after CABG is crucial.
Recent reports of successful simultaneous operations have encouraged us to adopt this procedure.6,7 We introduced combined CABG and AAA repair in 1990 for those patients in whom both lesions were considered to be indications for surgery. In this report, we summarize our experience and evaluate the feasibility of our strategy for these complicated situations.
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METHODS
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From June 1990 to May 2002, 29 patients underwent simultaneous CABG and AAA repair. During this period, seven patients had been planned for staged surgery by surgeons’ preference (n = 3) or patients’ request (n = 4). Cardiac function, number of coronary lesions or the size of AAA was comparable between simultaneous surgery and two-stage surgery (Table 1
). There was no patient who had severe respiratory, hepatic, or renal diseases in either group. There were 7 females and 22 males with a mean age of 65 ± 10 years (range, 43 to 78). Eleven patients had a history of old myocardial infarction and one had left ventricular aneurysm. All patients underwent coronary angiography (CAG) and left ventriculography. The mean number of coronary lesions and the left ventricular ejection fraction were 2.4 ± 0.6 and 62 ± 12 (mean ± S.D.), respectively. All AAAs but one of juxtarenal type were located infrarenally and were of arteriosclerotic type, and one was associated with periaortic inflammatory fibrosis. Maximal diameter of AAA was 64 ± 13 mm (range, 40 to 95). Either an AAA of more than 50 mm in size or an aneurysm of saccular type were considered as surgical indications. Five patients had dull pain in the lower abdomen and one had an intermittent claudication due to concomitant arteriosclerosis obliterans.
Carotid lesions were routinely evaluated by the duplex Doppler technology. If significant stenosis was found, carotid angiography and brain perfusion scintigraphy were indicated. In our strategy, significant carotid stenosis with confirmed hypoperfusion by the scintigraphy would be corrected simultaneously. However, there was no patient who had significant carotid lesions.
Twenty eight patients underwent CABG prior to AAA repairs and one underwent CABG and AAA repair simultaneously. Twenty-seven patients underwent standard coronary bypass grafting using cardiopulmonary bypass and two received off-pump CABG via a full sternotomy. In fourteen patients the left internal thoracic artery was grafted to the left descending artery. The mean number of bypass grafts was 2.5 ± 1.0 (range, 1 to 4). One patient underwent left ventricular aneurysmectomy concomitant with CABG. The mean durations of cardiopulmonary bypass and aortic clamp were 115 ± 38 minutes (range, 63 to 170) and 40 ± 23 minutes (range, 15 to 122), respectively. Patients received an extended midline incision from the sternal notch to the superior border of the pubic symphysis. The skin incision between chest and abdomen was separated in 4 patients. Twelve patients underwent laparotomy after administration of protamine and underwent AAA repair with additional heparinization. Fourteen patients received AAA repair under systemic full-heparinization, leaving arterial and venous cannulae to assist hemodynamics during AAA repairs. Three patients underwent AAA repair with the pump running. One of these patients had totally simultaneous CABG and AAA repair and another underwent AAA repair during warming of pump run. Bifurcated grafts were employed in 21 patients and straight grafts in 8. In one patient additional repair of a bilateral inguinal hernia was performed.
Data are presented as mean value ± standard deviation (S.D.). Comparisons were made using the chi-square or Student’s t-test for independent samples, as appropriate. Significant differences were reported for p values less than 0.05.
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RESULTS
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The mean duration of surgery was 400 ± 87 minutes (range, 297 to 605). One patient died of mediastinitis and postoperative cerebral infarction; hospital mortality was 3.5%. No patient developed myocardial infarction nor low output syndrome postoperatively. Two patients underwent re-exploration thoracotomy for mediastinal bleeding. Two patients had superficial wound infections requiring additional procedures. Two patients, including the one hospital death, developed postoperative stroke. Twelve patients (46%) did not receive homologous blood transfusion, while mean volume of homologous blood transfusion was 1030 ± 1540 ml (range, 0 to 4800) during the hospitalization period. The mean and median postoperative hospital stay was 26 ± 20 and 18 days, respectively. Hospitalization was briefer in the one-stage surgery group, as was duration of surgery, compared with patients who underwent a two-stage operation (Table 1
). One patient in the staged surgery group died of rupture of AAA four weeks after CABG.
The mean follow-up was 5.5 ± 3 years (range, 0.4 to 11.5). One death was of non-cardiovascular origin. No patients developed recurrent angina or myocardial infarction. No patients had vascular complications after AAA repair.
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DISCUSSION
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AAA and coronary artery disease are highly coexistent, while CAD is one of the major causes of perioperative mortality. Furthermore, CAD is the most common cause of late death in patients with AAA repairs.3,6 Surgeons treating patients with coexistent CAD and AAA should consider competing goals to prevent cardiac morbidity while avoiding AAA rupture. For patients presenting severe CAD and AAA, the available surgical options are combined CABG and AAA repair or staged repair of AAA following CABG.
Blackbourne et al. reported that in a staged procedure with an interval of more than 2 weeks between the procedures, a 30% incidence of AAA rupture was observed.5 In our experience one of seven patients (14%), in whom staged operation had been planned, died of AAA rupture 4 weeks after CABG. The inflammatory response caused by CPB may have a direct effect on the aneurysm wall, leading to decreased tensile strength and further dilatation. Furthermore, increased collagenase activity following major surgery appears to be a key factor in early AAA rupture.
Cross-clamping the abdominal aorta increases the afterload to the myocardium. This results in an increase in left ventricular wall stress, which may adversely affect subendocardial perfusion, finally leading to myocardial ischemia and the depression of cardiac function. A decrease in cardiac index and LVEF has been demonstrated following abdominal aortic clamping with coronary artery disease.8,9 In patients with impaired left ventricular function, AAA repair during CPB is desirable.10–12 In the recent series, we routinely retained the arterial and venous cannulae so as to assist hemodynamics during AAA repair. This method is useful not only for rapid volume adjustment and afterload unloading but also for avoiding temperature loss during the abdominal procedure.13
We believe a one-stage operation consisting of both CABG and AAA repair is a safe and effective procedure that also reduces cost.13 Not only the danger of repeat anesthesia in a population at high risk but also the risk of AAA rupture following CABG can be avoided. From the economic point of view, the simultaneous approach may also be cost effective when compared with a two-stage procedure requiring two hospitalizations.14
We have experienced no significant increase in mortality associated with this procedure. However, morbidity with stroke and wound infection was considerable in comparison with ordinary CABG or AAA repair. These may be associated with increased total operation time. The combined operation is a major surgical procedure and should be reserved for surgeons who are skilled in both cardiac and vascular surgery and working closely together with an experienced cardiovascular anesthesiologist.14 Ascione et al. reported that off-pump CABG decreased postoperative complications in high-risk patients undergoing simultaneous coronary and abdominal aortic operations compared with the conventional one-stage procedure.15 Thus, the off-pump strategy may be one of the options for reducing mortality and morbidity in combined CABG and AAA repair.
We had no experience of acute renal and / or respiratory insufficiency postoperatively. However, both severe pulmonary disease and chronic renal failure will increase the risk of a combined approach and worsen the prognosis for these patients.16–18 Therefore, the most appropriate indication for combined surgery remains unresolved.
In conclusion, this study suggests that combined coronary artery bypass grafting and abdominal aortic repair is safe and effective. It is now appropriate to conduct a prospective, randomized study in order to support these conclusions.
This paper had been presented at the 10th Annual Meeting of Asian Society for Cardiovascular Surgeon (17th–19th April 2002, Jeju Island, Korea).
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REFERENCES
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TOP
ABSTRACT
Introduction
