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.