World Journal of Cardiovascular Surgery, 2011, 1, 1-4
doi:10.4236/wjcs.2011.11001 Published Online September 2011 (http://www.SciRP.org/journal/wjcs)
What Should Be Done if There Is Coronary Artery
Disorder in Ruptured Abdominal Aortic Aneurysm?
Erdal Simsek, Mehmet Bayraktaroglu, Huseyin Bayram, Sevket Atasoy, Salih Fehmi Katircioglu
Departman of Cardiovascular Surgery, Ankara Etlik İhtisas Training and Research Hospital, Ankara, Turkey
Received August 5, 2011; revised August 27, 2011; accepted September 4, 2011
Abstract
Abdominal aortic aneurysm (AAA) is the most common type of aneurismal diseases. Generally, it is asymp-
tomatic and when it is ruptured, it develops with high morbidity and mortality. Case report: A 62-years-old
male patient consulted our emergency with a pain at his dorsum and lumbar part. Cardiologist with a suspi-
cion of coronary artery disorder or dissection, coronary angiography was executed. Consecutive lesions of
LAD artery (left anterior descending) 40% - 50% and 90%, CX artery (circumflex) 40% and 80% - 90%, and
a lesion of RCA (right coronary artery) 20% - 30% were detected. With a suspicion of rupture, abdominal
aneurysm tomography (CT) was demanded. In the tomography, a 7-cm-diameter ruptured abdominal aortic
aneurysm was diagnosed. Levosimendan support was started. Under the support of levosimendan a Y graft
operation was performed. The operation was ended up with levosimendan support considering that coronary
bypass would increase mortality and morbidity. Discussion: Approximately 50% of the ruptured aneurysms
are died before they reach hospital while the 30% - 70% operated ones are died within 30 days after opera-
tion. Early diagnosis and follow-up is extremely important to decrease morbidity and mortality. The patients
consulting with rupture must be taken to the operation without delay. What should be done if coronary artery
disorder is detected in the patient whose AAA is ruptured and if the bypass is necessary? In our opinion, a
decision must be made according to the patient’s clinical condition. As a result of our case, we thought re-
pairing the abdominal aortic aneurysm necessitates the other comorbidites must be treated medically. We
aimed to decrease the cardiac oxygen requirement by starting levosimendan and decline afterload. If the pa-
tient, whose coronary artery disorder is detected, is under risk and his overall condition is bad, we think that
coronary bypass operation can be delayed.
Keywords: Abdominal Aortic Aneurysm, Coronary Artery Disease, Levosimendan
1. Introduction
Abdominal aortic aneurysm (AAA) forms the most
common type of aneurismal diseases. Generally, it is
asymptomatic and when it is ruptured, it develops with
high morbidity and mortality. While atherosclerosis gen-
erates the most frequent reason; smoking, male sex, hy-
pertension, hyperlipidemia and collagen tissue disorder
are the other risk factors.
2. Case Report
A 62-years-old male patient applied to our emergency
with a pain beginning from the chest and spreading to the
lumbar region. The patient’s blood pressure was 55
mmHg - 30 mmHg. With the support of intravenous so-
lution, his blood pressure was kept under acceptable lim-
its. With a suspicion of coronary artery disorder dissec-
tion, coronary angiography was executed. (Figure 1)
Consecutive lesions of LAD artery (left anterior de-
scending ) 40% - 50% and 90%, CX artery (circumflex)
40% and 80% - 90%, and a lesion of RCA (right coro-
nary artery) 20% - 30% were detected. Coronary an-
giography and then descendan, abdominal aortography
were performed with the suspicion of dissection; by the
way, abdominal aorta aneurysm was detected. With a
suspicion of rupture, abdominal ultrasound was applied
under emergency conditions. An aneurysm was detected

E. SIMSEK ET AL.
2
Figure 1. Coronary artery disease.
in USG and after the detection of flab in the aneurysm
cyst, with a suspicion of dissection, contrasty thora-
coabdominal tomography (CT) was demanded. In the
tomography, a 7-cm-diameter ruptured abdominal aortic
aneurysm was diagnosed. (Figure 2) In retroperitoneal
region, a 23 × 10 × 7-cm localized hematoma on the left
kidney was detected. The patient was taken to the inten-
sive care unit of cardiothoracic surgery. Levosimendan
infusion was started with the lowest dosage due to low
blood pressure. Chest pain was relieved after the infusion.
The patient was stabilized in terms of coronary artery
disease. His blood levels were Hgb 10 gr/dl, Hct 30%,
KB 70/30 mm Hg, pulse rate was 60/sec. He was oper-
ated under emergency conditions. Under the support of
levosimendan, abdomen was opened with median lapa-
rotomy and it was detected that the aneurysm was rup-
tured from left back side. A Y graft operation was carried
out from aorta to the bilateral iliac arteries by imple-
menting a surgical clamp from the region below the kid-
ney to the aorta. Excessive amount of hematoma was
cleared from the outer surface of the left kidney and
retroperitoneally. Because the patient’s overall condition
was deleterious and his hemodynamia wasn’t stable, the
operation was ended up with levosimendan support con-
sidering that coronary bypass would increase mortality
and morbidity. Because heparin usage was increased the
operation time. He didn’t experience hemodynamic
problem during his follow. 5 days after his operation, a
pneumonia infection was added. The patient whose
overall condition improved thanks to the suggestions of
thoracic medicine and infection was discharged healthily
18 days after the operation.
3. Discussion
Abdominal aortic aneurysm is a clinical condition which
Figure 2. Ruptured abdominal aortic aneurysm.
improves silently and deve lops with high mortality when
ruptured. Approximately 50% of the ruptured aneurysms
are died before they reach hospital while the 30% - 70%
operated ones are died within 30 days after operation [1].
The mortality of aneurysms applied elective surgery
ranges between 2% and 6% [1]. Many studies have indi-
cated a significant unity between aneurysm and athero-
sclerosis [2-4]. Male patients, over the age 75, have the
risk of developing AAA 8 times more than female pa-
tients; in addition, smoking, the use of statin, male sex,
high serum total cholesterol and lower HDL cholesterol
increase the risk [1]. AAA can be diagnosed with the
help of physical examination, ultrasound and tomogram-
phy. In 3% of the cases, diagnosis cannot be achieved
with ultrasound. Early diagnosis and follow is extremely
important to decrease morbidity and mortality. After
being ruptured, excessive increase in morbidity and
mortality appears. The patients consulting with rupture
must be taken to operations in emergency. Most patients
don’t have the opportunity to have additional examina-
tions like coronary angio or etc. What should be done if
coronary arteries disorder is detected in the patient rup-
tured and bypass is necessary? It is obvious that the first
intervention is oblig atory to the ruptured AAA. However,
after the intervention to the aneurysm, should coronary
bypass be applied or should there be following? In our
opinion, a decision must be made according to the pa-
tient’s clinic . Does su bsequent coronary bypass operati on
increase morbidity and mortality? The existence of car-
diovascular disorders and depressed cardiac functions are
substantially significant in determining mortality and
morbidity [5]. The existence of coronary artery disorder
is an important factor to determine preoperative mortality.
If AAA, which cannot be ruptured, is enormous and
symptomatic, its rehabilitation can be done concurrently

3 E. SIMSEK ET AL.
with coronary bypass surgery [6]. If AAA is not enor-
mous and symptomatic, it can be rehabilitated 2 - 4 weeks
after the coronary bypass surgery [6]. When combined,
aneurysm rehabilitation can be done with beating bypass
or partial cardiopulmonary bypass. It is detected that
bleeding increases within the ones who had partial car-
diopulmonary bypass [6]. In the critical patients, if car-
diac functions and the oxygen amount reaching the heart
can be provided with in the opti mal co nd itions du ring and
after the operation, mortality and morbidity decrease
noticeably [7,8]. In our case, the patient has requiring
coronary bypass surgery. So to prevent this problem we
prefer to use levosimendan. So, we supplied cardiac sta-
bilization by increasing oxygen presentation and de-
creasing after- and pr e-load and oxygen consumption.
Levosimendan have cytoprotective vasodilator proper-
ties and treatment of non-compensated heart failure. Levo-
simendan enhances myocardial contractility, decreasing
myocardial oxygen co msumption [9]. It binds to calcium
saturated cardiac troponin C (cTnC), this effect of levo-
simendan was shown to be dependent on the concentra-
tion of intracellular ionized calcium (Enhanced myocar-
dial contractility, no increased oxygen consumption)
[10,11]. The second mechanism stimulates ATP-sensi-
tive potassium channels. (Anti stunning effects, anti is-
chaemic effects) Positive inotropic agents, phosphodi-
esterase inhibitors and ad renergic agonists such as dobu-
tamine, associated with increasing myocardial oxygen
demand and the potential to induce myocardial ischaemia
or malignant arrhythmias [12,13]. Levosimendan may
also exert vasodilator effects on human coronary con-
ductance and resistance arteries [14]. After the drug in-
fusion, coronary artery diameter, velocity, and flow in-
crease significantly [14]. The most commonly adverse
effects associated with the use of levosimendan are hy-
potension, headache, dizziness and nausea.
We avoided to use heparin requiring procedures be-
cause of our belief that heparin usage increases the
bleeding. That is why we are reluctant the coronary by-
pass surgery the aneurysm repair. As a result of our case
we thought that while repairing the abdominal aortic
aneurysm the other comorbidites must be treated wıth
medically.
Our patient consulted us with a shock state and his
overall condition was bad. We aimed at decreasing the
cardiac oxygen requirement by starting levosimendan
and declining afterload. We increased the cardiac supply
by rising blood pressure a bit. Considering that an appli-
cation of coronary bypass would increase morbidity and
mortality, we decided to follow up. If the patient, that has
coronary artery disorder, is under risk and his overall
condition is bad, we think that coronary bypass operation
can be delayed.
4. References
[1] S. H. Forshdahl, K. Singh, S. Solberg and B. K. Jacobsen,
“Risk Factors for Abdominal Aortic Aneurysms a 7-Year
Prospective Study: The Tromso Study, 1994-2001,” Cir-
culation, Vol. 119, 2009, pp. 2202-2208.
doi:10.1161/CIRCULATIONAHA.108.817619
[2] K. Singh, K. H. Bonaa, B. K. Jacobsen, L. Björk and S.
Solberg, “Prevalence of and Risk Factors for Abdominal
Aortic Aneurysms in a Population—Based Study: The
Tromso Study,” American Journal of Epidemiology, Vol.
154, No. 3, 2001, pp. 236-244. doi:10.1093/aje/154.3.236
[3] D. Reed, C. Reed, G. Stemmermann and T. Hayashi,
“Are Aortıc Aneurysms Caused by Atherosclerosis?”
Circulation, Vol. 85, 1992, pp. 205-211.
[4] A. J. Lee, F. G. Fowkes, M. N. Carson, G. C. Leng and P.
L. Allan, “Smoking, Atherosclerosis and Risk of Ab-
dominal Aortic Aneurysm,” European Heart Journal,
Vol. 18, No. 4, 1997, pp. 671-676.
[5] S. Giordano, F. Biancari, P. Loponen, J. Wistbacka and
M. Luther, “Preoperative Haemodynamic Parameters and
the Immediate Outcome after Open Repair of Ruptured
Abdominal Aortic Aneurysms,” İnteractive Cardiovas-
cular Thoracic Surgery, Vol. 9, 2009, pp. 491-493.
[6] T. Wolff, D. Baykut, H. R. Zerkowski, P. Stierli and L.
Gürke, “Combined Abdominal Aortic Aneurysm Repair
and Coronary Artery Bypass: Presentation of 13 Cases
and Review of the Literature,” Annals of Vascular Sur-
gery, Vol. 20, No. 1, 2006, pp. 23-29.
doi:10.1007/s10016-005-9324-9
[7] I. Kantonen, M. Lepantalo, J. P. Salenius, S. Matzke, M.
Luther and K. Ylönen, “Mortality in Abdominal Aortic
Aneurysm Surgery: The Effect of Hospital Volume, Pa-
tient Mix and Surgeon’s Case Load,” European Journal
of Vascular and Endovascular Surgery, Vol. 14, No. 5,
1997, pp. 375-379. doi:10.1016/S1078-5884(97)80287-0
[8] T. Juvonen, F. Biancari, J. Rimpilainen, V. Anttila, M.
Pokela, V. Vainionpaa, P. Romsi and K. Kiviluoma,
“Determinants of Mortality after Hypothermic Circula-
tory Arrest in a Chronic Porcine Model,” European Jour-
nal of Cardio—Thoracic Surgery, Vol. 20, No. 4, 2001,
pp. 803-810.
[9] J. Levijoki, P. Pollesello, J. Kaivola, C. Tilgmann, T.
Sorsa, A. Annila, I. Kilpelainen and H. Haikala, “Further
Evidence for the Cardiac Troponin C Mediated Calcium
Sensitization by Levosimendan. Structure—Response and
Binding Analysis with Analogs of Levosimendan,” Jour-
nal of Molecular and Cellular Cardiology, Vol. 32, No. 3,
2000, pp. 479-491. doi:10.1006/jmcc.1999.1093
[10] Z. Papp, K. Csapo, P. Pollesello, H. Haikala and I. Edes,
“Pharmacological Mechanisms Contributing to the Clini-
cal Efficacy of Levosimendan,” Cardiovasc Drug Review,
Vol. 23, No. 1, 2005, pp. 71-98.
doi:10.1111/j.1527-3466.2005.tb00158.x
[11] D. P. Figgit, P. S. Gillies and K. L. Goa, “Levosimen-
dan,” Drugs, Vol. 61, 2001, pp. 613-627.
doi:10.2165/00003495-200161050-00006

E. SIMSEK ET AL.
4
[12] M. Bayram, L. De Luca, B. M. Massie and M. Gheor-
ghiade, “Dobutamine Milrinone and Dopamine in Acute
Heart Failure Syndromes: A Reassessment,” American
Journal of Cardiology, Vol. 96, No. 6, 2005, pp. 47-58.
doi:10.1016/j.amjcard.2005.07.021
[13] L. D. Caldicott, K. Hawley, R. Heppel, P. A. Woodman-
sey and K. S. Channer, “Intravenous Enoximone or
Dobutamine for Severe Heart Failure after Acute Miyo-
cardial Infarction: A Randomized Double-Blind Trial,”
European Heart Journal, Vol. 14, No. 5, 1993, pp.
696-700. doi:10.1093/eurheartj/14.5.696
[14] A. D. Michaels, B. McKeown, M. Kostal, K. T. Vakharia,
M. V. Jordan, I. L. Gerber, E. Foster and K. Chatterjee,
“Effects of Intravenous Levosimendan on Human Coro-
nary Vasomotor Regulation, Left Ventricular Wa ll Stress,
and Myocardial Oxygen Uptake,” Circulation, Vol. 111,
2005, pp. 1504-1509.
doi:10.1161/01.CIR.0000159252.82444.22