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Ann Thorac Surg 1998;66:1273-1276
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Simultaneous coronary artery bypass grafting and abdominal aneurysm repair decreases stay and costs

^a Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA

Accepted for publication April 30, 1998.

Address reprint requests to Dr Kron, Department of Surgery, University of Virginia Health Sciences Center, Box 310, Charlottesville, VA 22908
e-mail: (ikron{at}virginia.edu)

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Patients with large (5.0 cm) abdominal aortic aneurysms (AAA) frequently have marked associated coronary artery disease. We hypothesized that a single operation for coronary artery bypass grafting (CABG)/AAA would provide equivalent, if not improved, patient care while decreasing postoperative length of stay and hospital costs compared with staged procedures.

Methods. Eleven patients to date have undergone a combined procedure at our institution. Ten underwent CABG followed by AAA repair, whereas one patient received an aortic valve replacement before aneurysm repair. We performed a retrospective analysis comparing the postoperative length of stay and hospital costs for this single procedure to a combined cohort of 20 randomly selected patients who either received AAA repair (n = 10) or standard CABG (n = 10) during the same time period.

Results. No operative mortality has been reported. There were no episodes of neurologic deficit or cardiac complication after these procedures. The postoperative length of stay was significantly decreased for the CABG/AAA group compared with the combined postoperative length of stay for the AAA plus CABG group (7.44 ± 0.88 days versus 14.10 ± 2.00; p = 0.012). Total hospital costs were also significantly decreased for the CABG/AAA group compared with total hospital costs for the AAA plus CABG group ($22,941 ± $1,933 versus $34,076 ± $2,534; p = 0.003).

Conclusions. A single operation for coronary revascularization and AAA repair is safe and effective. Simultaneous CABG and AAA repair substantially decreases postoperative length of stay and hospital costs while avoiding possible interim aneurysm rupture and repeat anesthesia.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Abdominal aortic aneurysms (AAA) are frequently associated with clinically significant coexistent coronary artery disease. Up to 80% of patients with abdominal aortic aneurysms will have angiographic evidence of atherosclerosis in at least one coronary vessel; as many as 18% of these patients will have surgically correctable three-vessel coronary artery disease [1]. This clinical correlation has led several authors to recommend cardiac evaluation and coronary revascularization if indicated before AAA repair [2–5].

The timing of surgical repair of a severe AAA (5 cm) after coronary revascularization has generated debate in the past. Originally it was thought that the repair of a large AAA should be approached 6 weeks to 6 months after coronary revascularization. We previously reported that this delay in operative intervention led to an increased patient mortality owing to aneurysm rupture. We also demonstrated that aneurysm rupture in the early postoperative phase could be avoided if AAA repair was performed within 2 weeks of cardiac operations [6]. Several studies have demonstrated the safety and efficacy of a single operation for coronary artery bypass grafting (CABG) followed by AAA repair either on or off cardiopulmonary bypass [7–12]. We currently favor the performance of cardiac operations immediately followed by AAA repair during the rewarming phase with cardiopulmonary bypass catheters left in place until the completion of the operation.

A single operation avoids repeat anesthesia and prevents two separate convalescence periods. Thus, a combined procedure could be justified providing there is no additional operative risk to the patient.

We hypothesized that a single operation for patients with surgically correctable coronary artery disease and a clinically significant abdominal aortic aneurysm would decrease both postoperative length of stay and hospital costs compared with the combined costs and postoperative length of stay for a staged procedure. We also hypothesized that a single operation would not result in increased patient morbidity or mortality compared with a staged procedure.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
We undertook a retrospective review of all patients who underwent a combined procedure or single operation for the repair of an asymptomatic AAA greater than 5 cm in diameter preceded by either coronary revascularization or valve replacement. Between January 1991 and January of 1997, 10 patients underwent CABG immediately followed by AAA repair; 1 patient received an aortic valve replacement before AAA repair. We then compared this group’s postoperative length of stay and hospital costs with a combined cohort of 20 randomly selected patients (AAA plus CABG) who received either AAA repair (n = 10) or standard CABG (n = 10) during this same time period. Patient demographics for these two groups are summarized in Table 1.

Surgical procedures
All CABG (n = 10) patients underwent standard bypass grafting via a median sternotomy on cardiopulmonary bypass with or without the use of an internal mammary artery as a conduit to the left anterior descending coronary artery. One patient in this group underwent aortic valve replacement at the time of CABG. One patient was taken back to the operating room for control of mediastinal bleeding postoperatively, whereas one underwent sternal debridement and closure for a sternal wound infection (Table 1).

All AAA (n = 10) patients underwent repair of their infrarenal aneurysms as described by Javid and Julian [13]. Additional operations at the time of AAA repair in this group included a single incidence of reimplantation of the inferior mesenteric artery; one patient underwent bilateral femoral artery profundoplasty and endarterectomy. There were no operative complications for this group. However, one patient’s hospital stay was lengthened by 7 days owing to a mild case of pancreatitis, whereas another patient experienced an episode of acute renal failure which resolved spontaneously without hemodialysis (Table 1).

Patients in the CABG/AAA (n = 10) group received an extended midline sternotomy with an incision from the sternal notch to the superior border of the pubic symphysis. This group then underwent simultaneous dissection of the thoracic and abdominal cavities with mobilization of the abdominal viscera and control of the AAA performed during the harvest of the internal mammary artery and saphenous vein graft. Once the bypass conduit had been harvested and exposure of the aneurysm was completed, the abdominal cavity was packed with moist lap pads and covered with sterile towels. The patient was then cannulated and placed on cardiopulmonary bypass. Coronary artery bypass grafting was then performed in standard fashion. Once bypass grafting was completed, the heart was defibrillated and rewarming was initiated. If the heart demonstrated good contractility and adequate perfusion pressures as bypass was weaned, attention was then turned toward completion of the AAA repair as previously described [13]. The patient remained cannulated and heparinized throughout the completion of the AAA resection and repair. After completion of the AAA repair, the patient was decannulated and heparin was reversed. Adequate hemostasis was ensured and simultaneous closure of the thoracic and abdominal cavities was performed.

Four patients underwent additional procedures at the time of CABG/AAA repair. These additional procedures included aortic valve replacement, cholecystectomy, and two left renal artery reconstructions. Two patients underwent reoperation. One patient was taken back to the operating room for mediastinal bleeding, and another for closure of an abdominal fascial dehiscence.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
There were no significant differences with regard to age, gender, size of AAA, number of bypasses, ejection fraction, or cross-clamp time. The patients in the CABG/AAA group spent a significantly longer time on cardiopulmonary bypass compared with the CABG group (58.45 ± 7.98 minutes versus 41.20 ± 5.50 minutes; p = 0.024). There were similar incidences of postoperative morbidity for each of the three groups. There was no operative mortality for any of the three groups.

There was a significant decrease in postoperative length of stay for the CABG/AAA group compared with the combined length of stay for the AAA plus CABG group (7.44 ± 0.88 days versus 14.10 ± 2.00 days; p = 0.012). There was also a significant decrease in total hospital costs for the CABG/AAA group compared with the combined AAA plus CABG group ($22,941 ± $1,933 versus $34,076 ± $2,534; p = 0.003). Similar significant decreases in indirect costs, direct costs, and total charges were demonstrated and are summarized in Table 2.

	Comment

Top Abstract Introduction Material and methods Results Comment References

The increased incidence of AAA rupture after major abdominal and thoracic operations has been well documented [14–16]. Multiple operative and postoperative factors may play a role in hastening aneurysm rupture. Hemodynamic instability leading to volatility in systemic blood pressure may complicate a patient’s course after CABG leading to further aneurysm dilation and subsequent rupture. The inflammatory response caused by cardiopulmonary bypass grafting may have a direct effect on the aneurysm wall leading to decreased tensile strength and further dilation. Collagen is believed to be the primary constituent of the aneurysm wall. Therefore, increased collagenase activity appears to be a key factor in both of these processes leading to early aneurysm rupture after major surgical procedures [17, 18]. Finally, perioperative malnutrition may play an important role in decreased collagen production and aneurysm rupture.

We have previously demonstrated that patients with surgically correctable coronary artery disease and an AAA 5 cm or greater in diameter should undergo coronary revascularization followed by AAA repair within 2 weeks [6]. A delay in AAA repair of greater than 6 weeks after CABG resulted in three deaths because of AAA rupture in a consecutive group of 9 patients. There were no deaths in the next 14 patients receiving either a combined approach or a limited staging period of 2 weeks.

We believe a single operation for CABG and AAA repair is a safe and effective procedure. We have experienced no increased morbidity or mortality associated with this combined procedure. Continued follow-up and further clinical studies should be carried out to ensure that operative morbidity and mortality remain low and that these patients suffer no long-term complications. Postoperative length of stay is notably decreased for patients undergoing combined CABG/AAA repair compared with those undergoing a staged approach. It is this decrease in length of stay that is primarily responsible for the significant reduction in hospital costs for these patients. The combination of previously staged procedures into a single operation can be an effective tool in reducing costs provided equivalent patient care is delivered.

There are many other advantages to the use of a single operation for coronary revascularization followed by AAA repair. Not only is the risk of aneurysm rupture eliminated after CABG; the risk of repeat anesthesia in a population with high operative risk is avoided. Patients with significant atherosclerosis of the aorta could undergo simultaneous CABG/AAA while limiting the risk of embolic catastrophe associated with cross-clamping the severely diseased aorta. Finally, patient discomfort is decreased as he or she endures a single convalescent period owing to a single operation.

We conclude that a single operation for CABG and AAA repair is safe and effective. We currently recommend a simultaneous operation for patients with surgically correctable CAD and an abdominal aortic aneurysm greater than 5 cm in diameter. The need for concomitant vascular reimplantation, reconstruction, bifurcated graft, or a combination of these should not limit the simultaneous approach provided the cardiac procedure can be completed without complication or hemodynamic instability. A retroperitoneal approach is feasible in these patients and may avoid exposure of the abdominal viscera and its associated morbidities. Simultaneous CABG/AAA repair provides equivalent patient care and reduces the risk of postoperative aneurysm rupture, while decreasing postoperative length of stay and reducing hospital costs.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert C. King Patrick E. Parrino Curtis G. Tribble Irving L. Kron Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by King, R. C. Articles by Kron, I. L. Search for Related Content PubMed PubMed Citation Articles by King, R. C. Articles by Kron, I. L.