Coronary artery disease and poor left ventricular function are the most important risk factors for morbidity and mortality in patients undergoing abdominal aortic aneurysm repair. Effective screening programmes and prior revascularization procedures (percutaneous translumincal coronary angiography and coronary artery bypass graft surgery) have helped to decrease the risk of cardiac-related adverse events. There is, however, a subgroup of patients presenting with both severe coronary artery disease and/or severely impaired left ventricular function and an acutely expanding or extremely large aneurysm that represents a therapeutic challenge. Surgery is often denied to these patients for their high risk. For this selected subgroup combined coronary artery bypass graft surgery and abdominal aortic aneurysm repair rather than a staged approach represents a therapeutic alternative. This article summarizes the pathophysiological concept, that favours a simultaneous approach performing abdominal aortic aneurysm repair during cardiopulmonary bypass and updates the current indications and results for this extensive surgery.