Optimal Method of Coronary Endarterectomy for Diffusely Diseased Coronary Arteries

Outcomes of coronary artery bypass grafting with coronary endarterectomy: A systematic review and meta-analysis of recent studies

Objective: The aim of this systematic review and meta-analysis was to evaluate the short-term and long-term outcomes of coronary artery bypass grafting (CABG) with coronary endarterectomy (CE) versus isolated CABG.Methods: Studies evaluating outcomes of CABG with CE (CE-CABG) were searched from 1 January 2000 to 30 September 2022, on PubMed, Embase, and Cochrane databases. The primary outcome was 30 -days mortality. Secondary outcomes were postoperative myocardial infraction, low output syndrome, cardiac arrhythmia, renal dysfunction, and 5 years survival.Results: A total of 12 observational studies including 114,319 patients assessing CE-CABG (n = 35,174) versus isolated CABG (n = 79,145) were included. Compared to isolated CABG alone, CE-CABG was significantly associated with increased incidences of 30-days mortality (RR, 1.87; 95% CI, 1.73-2.07; p < 0.01), postoperative myocardial infraction (RR, 1.61; 95% CI, 1.26-2.05; p < 0.01), low output syndrome (RR, 1.54; 95% CI, 1.17-2.02; p < 0.01), and renal dysfunction (RR, 1.56; 95% CI, 1.44-1.69; p < 0.01). However, there was no difference in either rate of cardiac arrhythmia (RR, 1.06; 95% CI, 0.97-1.15; p = 0.20) or 5 years survival (RR, 1.05; 95% CI, 0.95-1.16; p = 0.34) between the CE-CABG group and the control group. Subgroup analysis on CE technique showed that CE-CABG was also associated with 30 days mortality in patients undergoing closed CE (RR, 1.49; 95% CI, 1.09-2.03), whereas this association between CE and 30 days mortality was not observed in patients undergoing open CE (RR, 1.76; 95% CI, 0.58-5.32).Conclusions: Despite poor short-term outcomes, CE-CABG appeared to offer satisfactory long-term survival in patients with diffuse coronary artery disease.

Early tirofiban versus heparin for bridging dual antiplatelet therapy in patients undergoing coronary endarterectomy combined with coronary artery bypass grafting: a multicenter randomized controlled trial protocol (the THACE-CABG trial)

BACKGROUND

For complete revascularization, patients with diffuse coronary artery disease should have a coronary endarterectomy and a coronary artery bypass graft (CE-CABG). Sadly, CE can lead to a lack of endothelium, which raises the risk of thrombotic events. Even though daily dual antiplatelet therapies (DAPT) have been shown to reduce thrombotic events, the risk of perioperative thrombotic events is high during the high-risk period after CE-CABG, and there is no consistent protocol to bridge DAPT. This trial aims to compare safety and efficacy between tirofiban and heparin as DAPT bridging strategies after CE-CABG.

METHODS

In phase I, 266 patients undergoing CE-CABG will be randomly assigned to tirofiban and heparin treatment groups to compare the two treatments in terms of the primary safety endpoint, chest tube drainage in the first 24 h. If the phase I trial shows tirofiban non-inferiority, phase II will commence, in which an additional 464 patients will be randomly assigned. All 730 patients will be studied to compare major cardiovascular and cerebrovascular events (MACCEs) between the groups in the first 30 days after surgery.

DISCUSSION

Given the possible benefits of tirofiban administration after CE-CABG, this trial has the potential to advance the field of adult coronary heart surgery.

TRIAL REGISTRATION

chictr.org.cn, ChiCTR2200055697. Registered 6 January 2022. https://www.chictr.org.cn/com/25/showproj.aspx?proj=149451 . Current version: 20,220,620.

Distal anastomosis support for bypass grafting with coronary endarterectomy for the severe diseased posterior descending artery

BACKGROUND

The posterior descending artery is the most common vessel chosen for an endarterectomy, while endarterectomy to the posterior descending artery is associated with decreased graft patency. The purpose of this study was to describe a distal anastomosis support (DAS) technique and retrospectively investigate the effect of DAS on the mid-term graft patency.

METHODS

Between January 2016 and December 2018, 200 patients with a PDA severe lesion who underwent off-pump coronary artery bypass (OPCAB) with CE (OPCAB + CE group, n = 95) and OPCAB + CE with DAS for anastomosis of PDA grafted by saphenous vein (SVG) (OPCAB + CE + DAS group, n = 105) were evaluated retrospectively. All patients came back to follow-up visit 6th, 12th, 24th, and 36th postoperative month. The primary endpoint is the graft failure (FitzGibbon B or O) of SVG-PDA on the follow-up CTA or CAG.

RESULTS

There was no significant difference in perioperative outcomes. We found significantly improved cumulative graft patency in OPCAB + CE + DAS group at 36 months after operation (84.6% vs 76.5%, p = 0.02). In multivariate Cox regression analysis, plaque length larger than 2 cm (hazard ratio [HR], 13.108, 95% confidence interval [CI], 2.842-60.457, p = 0.001), and peak TNI ⩾70× ULN within 48 hours of surgery (HR, 3.778, 95% CI, 1.453-9.823, p = 0.006) were independent predictors of graft failure, whereas PDA diameter greater than 1.5 mm (HR, 0.231, 95% CI, 0.081-0.654, p = 0.006), and DAS use (HR, 0.336, 95% CI, 0.139-0.812, p = 0.015) were significant protective factors.

CONCLUSIONS

Concomitant DAS conferred superior mid-term patency of SVG-PDA. Adding the DAS procedure to OPCAB + CE may be a promising surgical option for patients with a PDA severe lesion, especially when PDA diameter less than 1.5 mm and plaque length greater than 2 cm.

Antithrombotic regimens in patients after coronary artery bypass grafting and coronary endarterectomy

Background: Coronary artery bypass grafting (CABG) remains the gold standard in the treatment of complex chronic forms of coronary heart disease (CHD). Coronary endarterectomy (CEAE) is a useful adjunctive technique to CABG in patients with diffuse coronary artery disease. In order to maintain the patency of the coronary arteries and graft conduits, various antithrombotic protocols have been introduced over the years, combining various antiplatelet and anticoagulant drugs, but still there is no consensus.

Aim: The aim of the study is to compare results between two antithrombotic regimens after CEAE. The first one is a combination of acenocoumarol combined with acetylsalicylic acid (ASA), the second regimen is a dual antiplatelet therapy (DAPT) of clopidogrel combined with ASA.

Material and methods: We retrospectively reviewed 56 consecutive patients (60 ± 8.2 years) undergoing isolated CABG in association with CEAE between January 2018 and December 2019. In the postoperative period, patients were divided into two groups according to the antithrombotic regimens described above. Twenty-four were in the ASA and acenocoumarol group (AA) and 32 were in the ASA and clopidogrel group (AC). Patients were followed up to 30 days after the operation and we access the mortality rate, new ECG changes, levels of myocardial fraction of creatinine phosphokinase (CPK-MB), left ventricular systolic function, pericardial or pleural effusions requiring drainage or revision for bleeding.

Results: Operative mortality was 3,6 %. No differences in the antithrombotic efficacy of the two regimens. A significantly higher level of hemorrhagic complications was observed in the ASA + acenocoumarol treatment group.

Conclusion: Dual antiplatelet therapy (DAPT) after CABG and coronary endarterectomy is an effective pharmacological regimen in regard to 30-day postoperative outcomes and is considerably safety in terms of bleeding complications.

Does the site of coronary endarterectomy have an impact on the clinical outcomes and graft patency?

OBJECTIVES

To explore whether coronary endarterectomy (CE) sites have obvious impacts on the clinical outcomes and graft patency in off-pump coronary artery bypass (OPCAB).

METHODS

The patients who underwent OPCAB with CE in our unit between January 2009 and December 2016 were included. The patients and the grafts were grouped according to the CE sites. The primary end points were mid-term main adverse cardiovascular and cerebrovascular events.

RESULTS

In total, 290 patients who underwent OPCAB with CE were included. CE of the left anterior descending artery (LAD), left circumflex artery and the right coronary artery was performed in 46, 30 and 194 patients, respectively. There were 60, 42 and 217 grafts anastomosed to LAD-CE, left circumflex artery-CE and right coronary artery-CE sites in 290 patients. CE was not performed in the 20 patients requiring multivessel CE. There was no significant difference in perioperative outcomes. The average follow-up time was 51 months (12-103 months). There was no significant difference in mid-term death, main adverse cardiovascular and cerebrovascular events, myocardial infarction (MI), stroke, Canadian Cardiovascular Classification for angina class and 1-year graft patency among the 3 groups. However, the rate of New York Heart Association (NYHA) class III or IV (LAD vs left circumflex artery: 59% vs 25%, P = 0.011; LAD vs right coronary artery: 59% vs 27%, P < 0.001) was higher in the LAD group than in the other groups. These results were consistent with the Kaplan-Meier curves of freedom from the adverse events.

CONCLUSIONS

CE sites had no obvious impact on mid-term death, main adverse cardiovascular and cerebrovascular events, MI, stroke, Canadian Cardiovascular Classification for angina class and 1-year graft patency in patients who underwent OPCAB with CE. The patients undergoing LAD-CE had higher rates of NYHA class III or IV.

Off-pump onlay-patch grafting using the left internal mammary artery for a diffusely diseased left anterior descending artery: in-hospital and mid-term outcomes

BACKGROUND

The aims of this study were to evaluate the in-hospital and mid-term outcomes of the off-pump onlay-patch grafting procedure using the left internal mammary artery (LIMA) for a diffusely diseased left anterior descending artery (LAD) and to identify the risk factors for postoperative LIMA graft failure in a single-center retrospective study.

PATIENTS AND METHODS

A total of 63 patients (52 males, 65.7±9.0 years) undergoing LAD arteriotomy with or without concomitant endarterectomy, followed by reconstruction using LIMA onlay-patch at the time of off-pump coronary artery bypass grafting at our institute from January 2014 to December 2016 were reviewed. The operative mortality, major postoperative morbidity, follow-up all-cause mortality, major adverse cardiac events at follow-up, and postoperative LIMA graft patency were analyzed. The risk factors for postoperative LIMA graft failure on the basis of baseline and surgical characteristics were identified by multivariable logistic regression analysis.

RESULTS

Eighteen (28.6%) patients underwent concomitant open LAD endarterectomy. The operative mortality rate was 1.6%. Major postoperative morbidity included perioperative myocardial infarction (3.2%), low cardiac output (1.6%), and reoperation for bleeding (1.6%). During the follow-up period of 24.2±9.5 months, all-cause mortality was 1.7% and the incidence of major adverse cardiac events was 6.8%. No repeat revascularization was recorded. In total, 88.1% of LIMA grafts showed FitzGibbon grade A patency determined by noninvasive coronary computed tomography angiography during follow-up. In addition, concomitant LAD endarterectomy and intraoperative LIMA graft flow were found to be independent risk factors for mid-term LIMA graft failure by multivariable logistic regression analysis (odds ratio=2.681, 95% confidence interval: 1.314-9.856, P=0.007 and odds ratio=0.932, 95% confidence interval: 0.791-0.976, P=0.021, respectively).

CONCLUSION

Revascularization of a diffusely diseased LAD using the off-pump LIMA onlay-patch technique results in encouraging clinical outcomes with favorable angiographic results. Concomitant LAD endarterectomy and intraoperative LIMA graft flow are associated with the risk of postoperative LIMA graft failure.

Intimal regeneration after coronary endarterectomy and onlay grafting in coronary artery bypass grafting

OBJECTIVES

Coronary onlay grafting, with or without endarterectomy, has been widely used for the treatment of diffuse lesions. Recent studies have demonstrated excellent long-term patency and favorable remodeling of onlay anastomosis; however, the underlying mechanisms remain unknown. Here, we describe the mechanism of intimal regeneration based on postmortem pathological evaluation of a patient who had undergone onlay grafting with coronary endarterectomy.

METHODS

The onlay anastomosis was analyzed using a combination of immunohistological stainings, namely, H&E, vimentin, α-SMA, factor VIII, and Ki-67, to identify the source and mechanism of intimal regeneration after onlay grafting with endarterectomy.

RESULTS

Our results suggest that the regenerated endothelium derives from the smooth muscle cells of the endarterectomized media of the coronary artery and that it circumferentially covers the internal lumen of the arterial graft.

CONCLUSIONS

Intimal regeneration, derived from the smooth muscle cells of the endarterectomized coronary artery that proliferate toward the graft lumen, may be a key mechanism that underlies the observed favorable remodeling after onlay grafting during coronary endarterectomy.

Coronary endarterectomy: an old tool for patients currently operated on with coronary artery bypass grafting. Long-term results, risk factor analysis

Aim

Coronary endarterectomy (CE) may provide a useful adjunctive technique to coronary artery bypass grafting (CABG) in patients with diffuse coronary artery disease. Nevertheless, the incidence of complications still remains high, long-term results remain unclear, and no risk factors for late mortality have been completely described yet.

Material and methods

We retrospectively reviewed 90 consecutive patients (67 ±8.2 years) undergoing isolated CABG in association with CE between 2006 and 2013. Mean follow-up was 75.1 ±36.2 months (median: 84 months) and it was 100% complete (6755/6755 patient-months).

Results

Operative mortality was 4.4%, the incidence of perioperative myocardial infarction was 11%. Ten-year survival was 83.3 ±4.1%, freedom from cardiac death 92.7 ±2.9%, and freedom from major adverse cardiac and cerebrovascular events 58.2 ±10.2%. Independent predictors of late mortality were age older than 70 years at time of the surgery (p = 0.018) and chronic obstructive pulmonary disease (p = 0.036). Ten-year freedom from cardiac death was better after CE on the left descending coronary artery (LAD) (93.2 ±3.3%) in comparison to CE not on the LAD (74.6 ±10.2%), although this difference did not reach statistical significance (p = 0.102).

Conclusions

Although the incidence of perioperative myocardial infarction continues to be not negligible, in the presence of diffusely diseased coronary artery vessels CE associated with CABG appears to be a feasible adjunctive surgical tool, conferring satisfactory early and long-term outcomes. Coronary endarterectomy on the LAD confers a high probability of freedom from late cardiac death. Patients older than 70 years and those affected by a primary respiratory disease represent a new challenge on which to focus attention due to the increased risk of late death.

Coronary Endarterectomy: Recent Trends

Coronary Endarterectomy (CE) assures complete revascularization of the myocardium in case of diffusely diseased vessels and prevents residual ischemia. Recently cardiac surgeons are performing increasing number of coronary endarterectomy and it has evolved as an important adjuvant procedure in Coronary Artery Bypass Grafting (CABG). There are controversies regarding the efficiency of CE. CE is criticised for its higher rates of morbidity and mortality. At present the available evidence supports CE in Off Pump Coronary Artery Bypass surgery (OPCAB) and along with valvular procedures. Graft patency is better with open technique. Postoperative anticoagulation regimen though not uniform, the overall outcome remains the same. Therefore, it is important to focus on the current results to accept CE as a routine procedure like CABG.

Single versus double antiplatelet therapy in patients undergoing coronary artery bypass grafting with coronary endarterectomy: mid-term results and clinical implications

Objectives

Coronary endarterectomy (CE) represents a useful adjunctive technique to coronary artery bypass grafting (CABG) in the presence of diffuse coronary artery disease. Nevertheless, the long-term patency of the graft remains unclear, and no standard anticoagulation and antiplatelet protocols exist for use after CE. The aim of this retrospective study was to evaluate and possibly to clarify the role of single (SAT) versus dual antiplatelet therapy (DAT) at mid-term follow-up.

Methods

Between January 2006 and December 2013, CE was performed in 90 patients (mean age 67 ± 8.2 years) who also underwent isolated CABG. After surgery, 20 patients received aspirin 100 mg daily (SAT group), and 52 patients received aspirin plus clopidogrel 75 mg daily (DAT group). Clopidogrel was discontinued in the DAT group 12 months after the operation.

Results

The overall in-hospital mortality rate was 2.7% (SAT 0% vs DAT 3.8%; P = ns). Perioperative myocardial infarction was 12.3% (SAT 15.0% vs DAT 11.5%; P = ns), and major bleeding requiring surgical re-exploration was 4.1% (SAT 10.0% vs DAT 1.9%; P = ns). Mean follow-up duration was 71.3 ± 32.7 months (median 79 months), and was 100% complete (5208/5208 pt-months). At 7 years of follow-up, freedom from cardiac death was 84 ± 9% in group SAT versus 85 ± 5% in group DAT (P = ns); freedom from new percutaneous coronary intervention was 93 ± 6% versus 100% (P = ns), and freedom from major adverse cardiac and cerebrovascular events was 73 ± 10% versus 75 ± 6% (P = ns).

Conclusions

In patients with diffuse coronary disease, CE is a safe and feasible technique with acceptable mid-term results. No differences were observed in terms of major clinical outcomes between patients treated with single versus dual antiplatelet therapy at least in a mid-term period of follow-up.

Short- and Long-Term Patient Outcomes From Combined Coronary Endarterectomy and Coronary Artery Bypass Grafting: A Meta-Analysis of 63,730 Patients (PRISMA)

This meta-analysis aimed to compare the short- and long-term outcomes in patients undergoing combined coronary endarterectomy and coronary artery bypass grafting (CE + CABG) versus isolated CABG, and particularly to examine subgroup patients with high-risk profile and patients with diffuse disease in the left anterior descending artery (LAD).Studies published between January 1, 1970 and May 31, 2015 were searched in the literature databases, including Ovid Medline, Embase, PubMed, and ISI Web of Science.A total of 30 eligible studies including 63,730 patients were analyzed.Five authors extracted data from the included studies independently.Meta-analysis on the total patients revealed that CE + CABG was associated with significantly increased 30-day postoperative all-cause mortality compared with isolated CABG (OR = 1.86, 95% CI: 1.66-2.08, z = 10.99, P < 0.0001). Subgroup analysis on patients with high-risk profile and patients with diffuse disease in the LAD showed that 30-day mortality after CE + CABG was 2.6 folds (OR = 2.60, 95% CI: 1.39-4.86, z = 2.99, P = 0.003) and 3.93 folds (OR = 3.93, 95% CI: 1.40-11.0, z = 2.60, P = 0.009) of that after isolated CABG in the respective subgroup. In contrast, the mortality was comparable in CE + off-pump CABG and CE + on-pump CABG groups (OR = 0.53, 95% CI: 0.18-1.55, z = 1.16, P = 0.248). In addition, the incidences of perioperative myocardial infarction (MI) and 30-day postoperative complications, including low output syndrome (LOS), MI, ventricular tachycardia (VT), and renal dysfunction after CE + CABG were significantly higher than those after isolated CABG (all P < 0.05). In high-risk patient subgroup, CE + CABG significantly increased the incidences of postoperative LOS, MI, and renal function compared with isolated CABG (all P < 0.05). The incidence of perioperative myocardial after CE + CABG was 2.86 and 2.92 times of that after isolated CABG in high-risk patients and patients with diffuse disease in LAD, respectively. Analysis on the recent reports (published later than 2000) showed consistent results as the analysis including all the eligible reports. Long-term survival was comparable in CE + CABG and isolated CABG groups (hazardous ratio = 1.16, 95% CI: 0.32-4.22, z = 0.23, P = 0.819).CE + CABG appears to be associated with poor short-term outcomes, particularly in high-risk patients and patients with diffuse disease in the LAD.

Comparison of off-pump and on-pump coronary endarterectomy for patients with diffusely diseased coronary arteries: early and midterm outcome

BACKGROUND

Coronary endarterectomy (CE) is an alternative for the diffusely diseased left anterior descending (LAD), but its mid and long term results are largely questionable. This study is to compare the early to mid-term results between off-pump and on-pump coronary endarterectomy with coronary artery bypass grafting.

METHODS

212 consecutive patients underwent CE and bypass grafting for diffusely diseased LAD. Ninety-two patients undergoing CE with off-pump (group off-pump) were compared with 120 patients undergoing CE with on-pump (group on-pump). The main preference for selection to an off-pump CE surgery were the preoperative high risk factors, especially previous cerebrovascular accident、chronic obstructive pulmonary disease (COPD)、calcified ascending aorta and right coronary artery (RCA) critical stenosis >90%.

RESULTS

There were three deaths in this group with total operative mortality of 1.4%. The perioperative mortality of group off-pump (1.1%) was similar with that of group on-pump (1.7%). The postoperative myocardial infarctions rate was 2.8%. There was no significant difference as for the morbidity between the group off-pump and group on-pump. Among survivors, the patency rate of the LIMA-LAD anastomosis was 89.4%. There was no difference as for the grafts patency rate between the two groups. Kaplan-Meier survival revealed no significant difference between the two groups. Kaplan-Meier freedom from cardiac events requiring hospital re-admission and angina recurrence were similar in both groups.

CONCLUSIONS

On-pump or off-pump CE is a good technique with the same early and mid-term outcomes. In the series of off-pump CE, we have shown that the effect of OPCABG with CE appears to be durable, and mid-term clinical outcomes are encouraging. Despite the higher risk profile, hospital mortality and major complications in our study are comparable to those for CCE.

Coronary endarterectomy: new flavors from old recipes

Coronary endarterectomy is an old surgical procedure against coronary artery disease first described by Baily et al. in 1957. Despite its first adverse results, several current publications have shown that coronary endarterectomy with on-pump or off-pump coronary artery bypass grafting can be safely performed with acceptable mortality, morbidity, and angiographic patency rates. Coronary endarterectomy can assure complete revascularization supplying the myocardium with satisfactory blood flow in cases of a diffusely diseased left anterior descending artery or diffuse calcification, thus preventing residual ischemia. Hence, it is important to evaluate current results, rethink this old recipe, and redefine its indications.

Medium-term survival of diffuse coronary artery disease patients following coronary artery reconstruction with the internal thoracic artery

OBJECTIVE

Diffuse coronary artery disease makes cardiac surgeons hesitant regarding whether coronary artery bypass grafting (CABG) surgery is feasible or not. Coronary artery reconstruction using the internal thoracic artery (ITA) allows bypassing of coronary arteries with diffuse atheromatous plaques without systematically resorting to endarterectomy. The aim of the present study was to evaluate the medium-term results of coronary artery reconstruction.

METHODS

All patients undergoing coronary artery reconstruction using the ITA between 1999 and 2002 (233 patients) were included in the study. The mean age was 61.9 ± 9.8 years. Two hundred and eighty-one coronary artery reconstructions using the ITA were performed (mean length 3.6 ± 2 cm) for 514 CABGs. Coronary artery reconstruction using the ITA was associated with endarterectomy in 48 cases (17%).

RESULTS

In-hospital mortality was 2.6%. Follow-up data were compiled in December 2008. Mean follow-up was 73.4 ± 16.7 months. The actuarial survival rate at 7 years was 89.3 ± 2.1%, and 88% of patients were free of major cardiac events at 7 years.

CONCLUSIONS

Coronary artery reconstruction gives comparable medium-term results to conventional coronary surgery, even though it is indicated for patients with more severe lesions.

Early results of coronary artery bypass grafting with coronary endarterectomy for severe coronary artery disease

Background

Despite the existence of controversial debates on the efficiency of coronary endarterectomy (CE), it is still used as an adjunct to coronary artery bypass grafting (CABG). This is particularly true in patients with endstage coronary artery disease. Given the improvements in cardiac surgery and postoperative care, as well as the rising number of elderly patient with numerous co-morbidities, re-evaluating the pros and cons of this technique is needed.

Methods

Patient demographic information, operative details and outcome data of 104 patients with diffuse calcified coronary artery disease were retrospectively analyzed with respect to functional capacity (NYHA), angina pectoris (CCS) and mortality. Actuarial survival was reported using a Kaplan-Meyer analysis.

Results

Between August 2001 and March 2005, 104 patients underwent coronary artery bypass grafting (CABG) with adjunctive coronary endarterectomy (CE) in the Department of Thoracic-, Cardiac- and Vascular Surgery, University of Goettingen. Four patients were lost during follow-up. Data were gained from 88 male and 12 female patients; mean age was 65.5 ± 9 years. A total of 396 vessels were bypassed (4 ± 0.9 vessels per patient). In 98% left internal thoracic artery (LITA) was used as arterial bypass graft and a total of 114 vessels were endarterectomized. CE was performed on right coronary artery (RCA) (n = 55), on left anterior descending artery (LAD) (n = 52) and circumflex artery (RCX) (n = 7). Ninety-five patients suffered from 3-vessel-disease, 3 from 2-vessel- and 2 from 1-vessel-disease. Closed technique was used in 18%, open technique in 79% and in 3% a combination of both. The most frequent endarterectomized localization was right coronary artery (RCA = 55%). Despite the severity of endstage atherosclerosis, hospital mortality was only 5% (n = 5). During follow-up (24.5 ± 13.4 months), which is 96% complete (4 patients were lost caused by unknown address) 8 patients died (cardiac failure: 3; stroke: 1; cancer: 1; unknown reasons: 3). NYHA-classification significantly improved after CABG with CE from 2.2 ± 0.9 preoperative to 1.7 ± 0.9 postoperative. CCS also changed from 2.4 ± 1.0 to 1.5 ± 0.8

Conclusion

Early results of coronary endarterectomy are acceptable with respect to mortality, NYHA & CCS. This technique offers a valuable surgical option for patients with endstage coronary artery disease in whom complete revascularization otherwise can not be obtained. Careful patient selection will be necessary to assure the long-term benefit of this procedure.

Hospital Outcome of Coronary Artery Bypass Grafting and Coronary Endarterectomy

To compare hospital mortality and postoperative complications in patients with severe coronary artery disease undergoing coronary artery bypass grafting with or without coronary endarterectomy, 100 consecutive patients were divided into 2 groups of 50 patients each. Group 1 had coronary endarterectomy, and group 2 had no coronary endarterectomy. There were 87 men and 13 women, with a mean age of 54.79 ± 7.8 years; 48% had stable angina. The right coronary artery was endarterectomized in 22 patients, the left anterior descending artery in 21, and the left circumflex in 7. There were no significant differences in outcomes. There was 1 hospital death in each group. Perioperative myocardial infarction occurred in 2 patients in group 1 and 1 in group 2. Endarterectomy is a suitable option to achieve complete revascularization in patients with refractory angina and severe diffuse disease.

Mammary Artery Patch Reconstruction of Left Anterior Descending Coronary Artery

Most patients with diffuse coronary disease require endarterectomy for revascularization. In view of the high morbidity and mortality associated with coronary endarterectomy, patch angioplasty and reconstruction of the coronary artery was developed. We retrospectively evaluated 104 patients who underwent mammary artery patch angioplasty of the left anterior descending coronary artery. The procedure consisted of laying open the entire diseased segment of the coronary artery and patching it with an in-situ left internal mammary artery onlay patch, without endarterectomy, in an off-pump procedure. One (0.9%) patient died, 2 (1.8%) suffered perioperative myocardial infarction, and an intraaortic balloon pump was used in 2. The mean blood loss was 224 mL. Intensive care unit stay was 2.5 days, and hospital stay was 7.8 days. At 1-year follow-up, most patients were in New York Heart Association functional class I. Follow-up angiography was carried out in 16 patients and showed good patency of all anastomoses. Arterial patch reconstruction of the left anterior descending coronary artery can be performed safely and effectively in an off-pump procedure, with excellent early and intermediate results.

Surgical treatment of coronary multivessel disease

Coronary artery bypass grafting has had a significant impact on the treatment of angina, and has been the 'gold standard' since 1969. Its use and efficacy has been increased by revascularization in cardiac arrest and the use of the internal mammary artery. In parallel, catheter techniques have evolved by means of balloon dilatation and additional stenting. This has effected the referral to surgery despite the development of new arterialization techniques and minimally invasive surgery. As competing techniques, an acceptable equilibrium between surgery and stenting will be found within the next years.

Coronary endarterectomy in the current era

PURPOSE OF REVIEW

The increasing incidence of diffuse coronary artery disease in the current era challenges cardiac surgeons in accomplishing their goal of complete revascularisation. Although coronary endarterectomy is used with encouraging results in most institutions, there remains some controversy in its indications, technique, and results. The purpose of this review is to highlight the important evolutions of technique in the recent past.

RECENT FINDINGS

Despite the increased risk factors and comorbidities in patients presenting with diffuse coronary artery disease requiring coronary endarterectomy, the results of coronary endarterectomy are improving inline with the improvements in the results of conventional coronary artery bypass grafting surgery. The improving results of coronary endarterectomy in the left anterior descending artery are further clarified. The intra- and postoperative use of prostacyclin has been shown to be effective in reducing mortality and perioperative myocardial infarction. The technique of open coronary endarterectomy with on-lay patch bypass grafting has been shown to be safe and effective in reducing mortality and improving patency as compared with the closed (traction) method of coronary endarterectomy. The use of coronary endarterectomy was also found to be effective in the treatment of in-stent restenosis in the setting of diffuse coronary artery disease. The results of off-pump coronary endarterectomy are encouraging and comparable with the conventional coronary endarterectomy using cardiopulmonary bypass.

SUMMARY

With the increasing incidence of diffuse coronary artery disease and improving results of coronary endarterectomy, it is vital for cardiac surgeons to have coronary endarterectomy in their armamentarium to achieve complete coronary revascularisation.