The coexistence of severe coronary artery disease (CAD) and abdominal aortic aneurysm (AAA) is uncommon but presents a formidable management challenge. Both conditions carry high morbidity and mortality, and each surgical intervention increases the risk of complications related to the other. Rupture rates of large untreated AAAs after coronary artery bypass grafting (CABG) are reported as high as 33% within four weeks, while AAA repair in patients with unstable CAD can precipitate perioperative myocardial infarction.

We report the case of a 71-year-old Filipino female who presented with acute coronary syndrome. Coronary angiography revealed severe three-vessel CAD with distal left main involvement, and echocardiography demonstrated preserved systolic function. As part of her preoperative work-up, screening abdominal ultrasound identified a large infrarenal AAA measuring 6.6 × 6.0 cm, confirmed on CT aortography as saccular with hostile neck anatomy, rendering her unsuitable for endovascular repair.

A staged strategy was adopted. The patient underwent urgent CABG with an uneventful recovery. Three weeks later, she successfully underwent open aneurysm repair, with minor postoperative complications that resolved with conservative management. At follow-up, she was asymptomatic, hemodynamically stable, and actively participating in cardiac rehabilitation.

This case highlights the value of preoperative abdominal ultrasound screening in older patients with CAD, even when abdominal findings are absent. Early detection of AAA altered surgical planning and likely prevented fatal rupture. A staged approach—CABG first to stabilize myocardial perfusion, followed by early open AAA repair—balanced rupture prevention with myocardial protection, achieving favorable outcomes.

In resource-limited settings such as the Philippines, this case underscores the importance of integrating vascular screening into preoperative cardiac protocols and demonstrates the efficacy of multidisciplinary decision-making in optimizing outcomes for complex dual pathology.

Dr. Muhammad Rajhi A. Amer is a Third-Year Cardiology Fellow-in-Training at the Heart and Vascular Institute of Perpetual Help Medical Center, Las Piñas, Philippines. He completed his Doctor of Medicine at De La Salle Health Sciences Institute in 2014 and his Internal Medicine residency at Rizal Medical Center, where he served as External Chief Resident in 2018. Prior to fellowship, he worked as a Medical Officer in Internal Medicine and Hemodialysis Units at Ospital ng Imus and Pagamutan ng Dasmariñas. 

He is also a graduate of Mindanao Sanitarium and Hospital College with a Bachelor of Science in Nursing, where he was recognized as a Dean’s Lister. His clinical and research interests include cardiac arrhythmias, structural heart disease, and advanced imaging.