Coronary Endarterectomy and Stent Removal in Patients With In-Stent restenosis

Stentectomy for LAD "full metal jacket" with in-stent restenosis: How to do it

We report our technique for the surgical revascularization of symptomatic severe in-stent restenosis of a "full metal jacket" (≥60 mm overlapping stents) of the left anterior descending coronary artery without suitable distal targets: on-pump cardioplegic-arrest stent removal (stentectomy) with endarterectomy and skeletonized left internal mammary artery onlay patch reconstruction. We also describe our follow-up protocol, including antiplatelet/anticoagulation and angiography. With proper patient selection, multidisciplinary collaboration, and surgical expertise, this advanced coronary procedure can be beneficial to a growing population of patients otherwise deemed to be untreatable.

In-stent restenosis: surgical and histopathological perspective

Background In-stent restenosis has been recognized as a distinct clinical entity that warrants a repeat procedure either in the form of percutaneous reintervention or coronary artery bypass grafting. Multivessel grafting with endarterectomy and explantation of the stent is rarely performed, with few cases reported in the literature. We aim to study the pathomorphology of the stent-vascular interface in coronary vessels undergoing in-stent restenosis. Methods Over a period of 3 years, 3 patients who had undergone angioplasty for diffuse coronary artery disease developed in-stent restenosis and were advised coronary artery bypass. The mean age was 53 years, the average time from the previous intervention was 77 months. Coronary endarterectomy with stent removal and concomitant multivessel coronary artery bypass was performed. Results Histology showed significant proliferation of the well-endothelialized intima as the reason for in-stent restenosis. There were no signs of local thrombus formation or increased inflammatory activity in any of the specimens. After coronary artery bypass, all patients were asymptomatic at a mean follow-up of 32 months. Conclusion Coronary endarterectomy with stent explantation and multivessel coronary artery bypass is a procedure that requires attention because the need is increasing due to the rise in the number of angioplasties. The complexity of this procedure increases to the extent that the adventitia is involved during stent explantation.

Segmental clamp and distal perfusion technique for reducing myocardial ischemia during coronary onlay grafting on a beating heart

We present a segmental clamp with distal perfusion technique to reduce myocardial ischemia during onlay grafting, on a beating heart. After a proximal coronary arteriotomy for 2-3 cm, the distal artery is perfused through a cannula, with femoral arterial blood (distal perfusion with external shunt). During proximal and distal coronary snare clamping with distal perfusion, onlay anastomosis is performed, from the heel toward the point of cannula insertion. We then move the proximal clamp to the onlay area and open the graft, to get early proximal coronary reperfusion. The arteriotomy is extended, and this procedure is repeated to achieve complete beating heart onlay anastomosis. We safely performed this procedure on the beating heart off-pump or on-pump in 95 patients with no perioperative myocardial infarction, no intraoperative hemodynamic deterioration, no 30-day mortality. This technique reduces regional myocardial ischemic and secures the safety for onlay grafting on the beating heart.

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.