Single Stage CABG and Peripheral Arterial Bypass for Combined Coronary and Peripheral Arterial Disease Divya Arora, Ashok Chahal and Shamsher Singh Lohchab Pt B D Sharma PGIMS Rohtak Haryana NCR Delhi

Disclosures NONE

Introduction Peripheral arterial disease and coronary artery disease often coexist former indicator of systemic atherosclerosis Ouriel K. Peripheral arterial disease. Lancet 2001;358:1257–1264. Majority of patients with lower extremity PAD requiring surgery have significant CAD. The prevalence of serious angiographic CAD ranges from 37% to 78% in patients undergoing operation for peripheral arterial disease. J Am Coll CardioI1991;18:203-14

Introduction All-cause mortality for combined lower-extremity PAD and CAD is approximately twice as high as that resulting from either of the individual conditions. Management of combined disease a challenge many controversial issues for optimal treatment strategy.

Challenge It seems … to be one of those simple cases which are so extremely difficult. Sherlock Holmes

Options Peripheral artery bypass and medical management of CAD PCI and Peripheral artery bypass Not suitable for PCI option remains simultaneous surgery for both.

Peripheral bypass and medical management of CAD Intra-operative and post-operative surveillance for myocardial ischaemia, infarction, and arrhythmias is important since peri- operative MI has been associated with 30–50% peri-operative mortality and reduced long-term survival. Fleisher LA et al.Circulation 2009;120:e169-e276

PCI and Peripheral artery bypass If revascularization by PCI is performed, postponing non-urgent vascular surgery for 14 days at least 6 weeks but preferably 3 months after bare metal stent. Fleisher LA Circulation 2009;120:e169-e276 Poldermans D et al. Eur Heart J 2009;30:2769-2812 1 year after drug-eluting stent, is recommended to decrease the risk of coronary/stent thrombosis peri-operatively Nuttall GA et al. Anesthesiology 2008;109:588-595 Anesthesiology 2008;109:596-604.

Peri-operative and long-term morbidity and mortality in patients undergoing non-cardiac vascular surgery with combined coronary artery disease Peri-operative  Eagle et al. Increased cardiac events from 3 to 8.5% after non-cardiac vascular surgery Coronary Artery Surgery Study. Circulation 1997;96:1882- 1887.pmid:9323076 Late Farkouh et al. Decreased survival at 10 years (24 vs. 51%) and increased cardiac events at 5 years (50 vs. 28%) after lower extremity vascular surgery J Am Coll Cardiol 1994;24:1290-1296.

Dilemma Patients Presenting with severe claudication and limb threatening ischemia deny coronary symptoms as unable to walk Execise ECG not feasible Stress Echo and CAG If significant CAD found do not want CABG due to denial of symptoms of CAD

Methods From January 2014 to August 2016 36 patients all males mean age 62 ± 7 years range 45 to 73 years underwent concomitant off pump CABG and peripheral arteria bypass These patients presented with severe lower limb ischemia Lower extremity CT angiography demonstrated Infra renal aortoiliac disease in 9(25%) patients Isolated external iliac occlusion in 12 (33%) superficial femoral artery occlusion in 15 (42%)

Methods CAG- Significant double vessel coronary occlusion was found in 12(33%) Triple coronary disease in 24 (67%) LV dysfunction was there in 24 (50%). There were 9(25%) diabetic patients

Strategy for aortoiliac disease was single stage abdominal aortobifemoral bypass grafting first followed by off pump CABG keeping in view the need for IABP.

Strategy For isolated iliac artery disease –Cross over femorofemoral bypass after completion of CABG. For superficial femoral artery, Femoropopliteal bypass after completion of CABG.

Results The operative mortality observed was in 2/36 (5.5%) Postoperative complications observed were acute limb ischemia in 1/36 (2.7%). Renal failure 2/36 (5.5%). None of these patients required rexploration for excessive bleeding. Two patients required IABP support and in one patient the catheter was put through the one limb of aortobifemoral femoral graft 30/34 (88%) patients were asymptomatic at maximum follow up of 32 months range (3-32).

Conclusion Single stage off pump CABG and peripheral artery bypass can be performed safely and obviates the major cardiovascular events in patients presenting with severe lower extremity ischemia.