Combined revascularization of coronary and femoral arteries: a proposed alternative

Combined total arch replacement and bypass from the ascending aorta to the bilateral profunda femoris arteries

A 72-year-old woman who had aortic arch aneurysm was admitted. The patient was unable to walk without assistance because of aortoiliac occlusive disease. Total arch replacement and the ascending aorta to the bilateral profunda femoris artery bypass were performed during the same operation. On outpatient visits, the patient was able to walk with a cane and the ankle-brachial pressure index was markedly improved. This combined procedure is an option for patients with aortoiliac occlusive disease who are not candidates for alternate inflow procedures, especially when the patient has another indication for median sternotomy.

Aortic valvular insufficiency and postductal aortic coarctation with small aorta syndrome: one-stage surgical management using extra anatomic bypass through median sternotomy

A 30-year-old man who had undergone repair for coarctation of the thoracic aorta at age 7 and mitral valve annuloplasty at age 9 was admitted for shortness of breath and claudication of both lower legs. The pre-operative angiogram showed severe aortic regurgitation, moderate coarctation of the thoracic aorta beyond the left subclavian artery, a degree of hypoplasia of the infrarenal abdominal aorta, and total occlusion of both external iliac arteries. Aortic valve replacement, ascending-to-bilateral femoral arterial bypass, and end expanded polytetra fluoro ethylene (ePTFE) graft-to-descending aorta bypass was performed via a median sternotomy. Ascending-to-descending aortic bypass via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.

Simultaneous coronary artery bypass grafting and ascending aorta bifemoral bypass in small aorta syndrome

A 55-year-old man with severe coronary artery disease and aortoiliac occlusive disease with small aorta syndrome was admitted to our department with angina pectoris and bilateral claudication. Intravenous subtraction angiography showed total occlusion of the right common iliac artery and 99% stenosis of the left common iliac artery with a markedly hypoplastic infrarenal aorta only 9 mm in diameter. It also revealed 90% stenosis at the origin of the left subclavian artery. Coronary angiography showed total occlusion of the left anterior descending artery and 90% stenosis of the circumflex artery. Simultaneous coronary artery bypass grafting and an ascending aorta-bifemoral bypass were conducted using an in-situ right internal mammary artery graft, an autologous saphenous vein graft, and a Y-figured expanded polytetrafluoroethylene graft. Postoperative angiography showed grafts to the coronary and bifemoral arteries were patient. This combined procedure is useful for patients with coronary artery disease and aortoiliac occlusive disease, especially in those with small aorta syndrome.

Coronary artery revascularization concomitant with vascular surgery

Patients with vascular disease and coronary disease are usually treated initially by coronary artery bypass grafting (CABG), and vascular surgery is generally performed later. In this study we assessed the feasibility of combined CABG and vascular surgery in a single operation. Between 1988 and 1995, 16 patients received combined operations for vascular and cardiac lesions and the clinical results were assessed. There were no operative or hospital deaths. The mean time for operation was 421 min and the duration of the stay in the intensive care unit (ICU) was a mean of 3.6 days. In one patient with an ischemic left leg, the left internal thoracic artery (ITA) had become a collateral source of the ischemic leg, and the need for preoperative angiography of the ITA in such patients was indicated. The combined operation clearly takes longer than either vascular surgery or CABG alone, but the length of the postoperative intensive care unit stay was essentially the same as that after a single operation and the patient was still managed safely after the combined operation. In patient requiring both operations, the combined procedure therefore appears to be safe and to have a good clinical outcome.