INFRARENAL ABDOMINAL AORTIC-ANEURYSM REPAIR - DETECTION AND TREATMENTOF ASSOCIATED CAROTID AND CORONARY LESIONS

Management of carotid or coronary lesions associated with abdominal ao rtic aneurysm (AAA) remains controversial. To determine the influence of these lesions on the outcome of elective infrarenal AAA repair, we review our experience between January 1978 and December 1992. A total of 345 consecutive patients underwent infrarenal AAA repair. Procedure s were performed under emergency conditions in 62 patients (18%) and e lectively in 283 patients (82%). Carotid and coronary risk was assesse d in all 283 patients undergoing elective operations. There were 259 m en (91.5%) with a mean age of 68 years (range: 45-88 years) and 24 wom en (8.5%) with a mean age of 76 years (range: 59-92 years). Previous c ardiac manifestations included myocardial infarction in 57 patients (2 0%), angina in 50 patients (17.6%), coronary bypass grafting in 14 pat ients (14.9%), and coronary transluminal angioplasty in two patients. Cerebral ischemic attacks had been observed in 11 patients (3.8%) incl uding transient events in two cases. Carotid endarterectomy had been p erformed in two patients. Assessment of carotid artery risk using Dopp ler ultrasonography led to selective carotid angiography in six patien ts and carotid endarterectomy in two patients. Assessment of coronary risk using a cardiac stress test was performed in 204 patients. Result s were normal or subnormal in 132 patients (46.6%), abnormal in 21 pat ients (7.4%), and uninterpretable in 51 patients (18%). Coronary arter iography was performed in 151 patients (53.3%) for secondary assessmen t after the cardiac stress testing in 72 patients (25%) and for primar y assessment in 79 patients (27.9%). Significant coronary lesions were demonstrated in 52 patients (18% of the overall population; 34% of co ronary arteriography procedures). In 12 cases the lesions were not con sidered as threatening. In four cases the lesions were deemed inoperab le. In the remaining 36 cases the lesions were treated either by aorto coronary bypass grafting (34 cases) or percutaneous transluminal angio plasty (two cases). In 11 of the 36 treated cases the patient was asym ptomatic and had no history of coronary disease. In all cases AAA was treated by resection graft. Eight patients (2.8 +/- 1%) died during ho spitalization including two deaths related to preexisting cardiac insu fficiency. No death was attributed to preoperative work-up or treatmen t of associated lesions. With a mean follow-up of 62 months (range: 1- 14 years), late mortality involved 96 patients (33.9 +/- 3%) including 16 deaths due to cardiac causes (16.7 +/- 4%) and 10 due to stroke (1 0.4 +/- 3%). Actuarial survival including deaths during hospitalizatio n was 70.5 +/- 3% at 5 years and 41.4 +/- 5% at 10 years. Comparison o f these results with those previously reported supports our policy of performing carotid or coronary angiography in patients selected by non invasive tests.