1. 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

2. Disclosures
NONE

3. 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

4. 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.

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

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

7. 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

8. 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:
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: Anesthesiology 2008;109:

10. 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: pmid:
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:

11. 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

12. Methods
From January 2014 to August 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%)

13. 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

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

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

16. 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).

17. 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.