CONCOMITANT OCCLUSIVE DISEASE OF THE CORONARY-ARTERIES AND GREAT-VESSELS

Background. Although an increasing number of elderly and high-risk pat ients, including those with generalized atherosclerosis, are undergoin g coronary revascularization, few reports exist regarding the manageme nt of patients who have both occlusive disease of the great vessels an d coronary artery disease. Methods. Between 1972 and 1996, 31 consecut ive patients (mean age, 56.5 years; 74% men) with multivessel coronary artery disease and symptomatic occlusive disease of the great vessels (25 single-vessel, 80.6%; 6 multiple-vessel, 19.4%) had 40 great vess els reconstructed by transthoracic bypass (n = 17, 42.5%), transthorac ic endarterectomy (n = 8, 20%), or extrathoracic bypass (n = 15, 37.5% ). All patients had simultaneous coronary artery bypass grafting (mean , 2.6 grafts per patient), and 8 patients had 10 distal carotid bifurc ation endarterectomies (6 staged, 4 simultaneous). Results. The early primary patency rate was 100%, and symptoms resolved completely in all 31 patients. There was 1 in-hospital death (3.2%) in a patient who ha d a respiratory arrest 11 days after operation. Perioperative morbidit y included two myocardial infarctions (6.5%) and one opposite-hemisphe re, embolic stroke (3.2%). Long-term follow-up of the 30 survivors (16 7.4 patient-years; mean, 5.6 years per patient) documented 5- and 10-y ear actuarial survival rates of 88.6% and 60.4%, respectively, with a 100% late brachiocephalic primary patency rate. Ten-year actuarial rat es of freedom from the following events were as follows: death, 60.4%; myocardial infarction, 82.5%; stroke, 90.9%; percutaneous translumina l coronary angioplasty or redo coronary artery bypass grafting, 95.2%; and vascular operation or amputation, 78.4%. Conclusions. Depending o n the anatomic distribution of the disease, an integrated approach to great vessel reconstruction that incorporated transthoracic and extrat horacic approaches and techniques of endarterectomy and bypass resulte d in few adverse outcomes and excellent long-term patency. Simultaneou s revascularization of the great vessels and coronary arteries can pro duce immediate and long-term, symptom-free outcome with acceptably low operative risk. (C) 1998 by The Society of Thoracic Surgeons.