Surgical correction of coronary arterial disease associated with lesions of the aorta ad its major branches.

When a candidate for aortocoronary bypass has an associated lesion of the aorta orone of its major branches, a single operation may be indicated for correction of both problems. Three typical cases illustrate the concept of the combined approach to surgical management of coronary arterial lesions and associated carotid arterial disease, abdominal aortic aneurysm, and superficial-femoral arterial disease. An aortocoronary bypass candidate with carotid stenosis may be in imminent danger of both myocardial infarction and stroke. The selection of the proper sequence of operations under these circumstances is extremely important because any form of hypotension might produce a stroke. Cardiopulmonary bypass usually results in at least a transient reduction of the systemic pressure which would further compromise the blood flow across the tight stenosis of the carotid artery. Therefore, we recommended repair of the carotid lesion before aortocoronary bypass is attempted in order to avoid the possibility of postoperative stroke. The combined presence of coronary arterial disease and abdominal aortic aneurysm is indication for operation, but resection of the aneurysm involves cross-clamping of the aorta, and subsequent changes in arterial pressure might impair the coronary circulation and lead to myocardial infarction. On the other hand, the systemic heparinization required for the establishment of cardiopulmonary bypass and arterial pressure changes could affect the integrity of aneurysm. Unless the abdominal aneurysm is expanding, however, we elect to perform coronay revascularization first, with resection and graft replacement of the aneurysm immediately after heparin reversal. Occlusive disease of the superficial femoral artery can be corrected immediately following aortocoronary bypass. Since the femoral and upper leg incisions have been performed, in certain cases it is convenient to complete the femoral popliteal bypass while the chest is being closed, thus saving a separate operation to correct the femoral occlusive disease.