Long-term angiographic results of coronary endarterectomy

Coronary endarterectomy combined with coronary artery bypass grafting might decrease graft patency: A cohort study

BACKGROUND

Little is known about the graft patency after coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG). This study aimed to investigate the graft patency after CABG + CE.

METHODS

Eligible patients hospitalized at our center during September 2008 and July 2022 with complete follow-up coronary angiographic data available were retrospectively enrolled. The primary end point was the follow-up graft patency of CE targets. Logistic regression was performed to explore the potential predictors of the CE-targeted graft failure.

RESULTS

A total of 160 patients (age: 59.4 ± 9.3 years, male: 75.6%) were enrolled, and 560 grafts were anastomosed. CE was performed on 166 sites, including LAD (36.1%), right coronary artery (RCA, 48.2%), left circumflex artery (9.6%), and diagonal branches (6.0%). Postoperative myocardial infarction was observed in 7 (4.4%) of the patients. During a median follow-up of 12.1 months, the CE-targeted graft patency was 69.9%. The CE-targeted graft patency rate was much higher among the LAD-CE patients than the non-LAD-CE patients (80.0% vs. 64.2%, P = 0.032) but lower than non-endarterectomized LAD (80.0% vs. 92.9%, P = 0.013). No difference was observed regarding the graft patency between off-pump and on-pump surgery (P = 0.585). In the logistic regression, RCA-CE was associated with an increased risk of graft failure even after multiple adjustments (odds ratio: 2.35, 95% confidence interval: 1.05-5.28, P = 0.028).

CONCLUSIONS

CABG + CE might be associated with decreased graft patency, especially in those who received RCA-CE, irrespective of surgical technique or antiplatelet/anticoagulation regimen. A multi-center prospective, possibly randomized study with a larger sample size is warranted.

Risk Prediction After Coronary Artery Bypass Grafting Combined With Coronary Endarterectomy

Coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) is used for complete revascularization of diffusely diseased coronary arteries. Nevertheless, studies reported an increased risk after this procedure. Therefore, risk prediction in these patients is essential. Patients who underwent CABG + CE during September 2008 and July 2022 at our center were retrospectively recruited. A total of 32 characteristics were analyzed. The least absolute shrinkage and selection operator regression were used for the feature selection, and multivariable Cox regression was applied to develop a nomogram for risk prediction. The primary outcome was the major adverse cardiovascular and cerebrovascular events (MACCE), a composite of all-cause death, nonfatal myocardial infarction, repeat revascularization, and stroke. A total of 570 patients with 601 CE targets, including left anterior descending (41.4%), right coronary artery (43.9%), left circumflex artery (6.8%), and diagonal branches/intermedius ramidus (8.0%), were enrolled. The mean age was 61.0 ± 8.9 years, and 77.7% were men. A total of 4 features were identified as the predictors of MACCE, including age ≥65 years (hazard ratio [HR] 2.12, 95% confidence interval [CI] 1.38 to 3.25, p <0.001), left main disease (HR 2.56, 95% CI 1.46 to 4.49, p = 0.001), mitral regurgitation (≥mild, HR 1.91, 95% CI 1.01 to 3.65, p = 0.049), and left anterior descending endarterectomy (HR 1.69, 95% CI 1.09 to 2.62, p = 0.018), and a nomogram for the 1- and 3-year MACCE prediction was developed. The model showed relatively good discrimination (C-index 0.68), calibration, and clinical usefulness. In conclusion, the nomogram provides estimation of the 1- and 3-year MACCE risk after CABG + CE.

Coronary endarterectomy in patients with diffuse coronary artery disease: assessment of graft patency with computed tomography angiography

Background:

With a growing population of patients with advanced coronary artery disease (CAD), many of whom have undergone prior percutaneous coronary interventions, coronary endarterectomy (CE) allows for the extension of revascularization in patients with otherwise limited options. Whether adjunctive CE associated with standard surgery, combined with contemporary antiplatelet therapy, improves outcomes remains largely unknown.

Methods:

We studied 147 consecutive patients who underwent 154 adjunctive CE procedures for advanced CAD between January 2015 and January 2018. We used computed tomography angiography (CTA) in a subgroup of 32 consecutive patients who underwent CE during coronary artery bypass grafting after June 2016 to assess graft and coronary patency.

Results:

Patients (mean age 67 ± SD 10 yr) underwent CE of the right (102 patients), the left anterior descending (LAD, 22 patients) and the circumflex (17 patients) coronary arteries. Seven patients (5%) experienced a procedural myocardial infarction and there were no perioperative deaths. Among the 32 patients who underwent CTA 3 months after surgery, the mean patency of the endarterectomized coronary arteries and bypass grafts was 90% and 88%, respectively. All 6 arterial grafts on the LAD artery were patent. The mean survival rate and the mean rate of freedom from major adverse cardiovascular events was 95% ± 2% and 95% ± 6%, respectively. The patency rate was 100 % for patients evaluated at 3-year follow up.

Conclusion:

Coronary endarterectomy offers a surgical option for patients with diffuse CAD who may be unsuitable for coronary bypass alone. Grafts and endarterectomized coronary artery patency remain adequate and explain the excellent patient survival and the freedom rate from major adverse cardiovascular events.

Coronary endarterectomy in coronary artery disease: Factors affecting graft patency and survival

BACKGROUND

Coronary endarterectomy aims to improve completeness of revascularization in patients with occluded coronary vessels. The benefits of coronary endarterectomy remain uncertain. The aim of this study was to evaluate short-term surgical outcomes and factors affecting graft patency post-coronary endarterectomy.

METHODS

Between 2009 and 2019, 81 consecutive patients who had coronary endarterectomy done were evaluated for their perioperative and early results. A total of 36 patients with follow-up coronary studies were included in patency analysis. Mortality rates, major adverse cardiac and cerebrovascular events, and graft patency were outcomes of interest. Survival and risk factor analysis were performed with Kaplan-Meier and logistic regression analysis.

RESULTS

The average age of the cohort was 61.9 ± 9.29 years. Complete revascularization rate was 95.4% post-coronary endarterectomy. The 30-day and 1-year mortality was 2.5 and 6.2%, respectively. One-year major adverse cardiac and cerebrovascular events rate was 11.1%. Periprocedural myocardial infarction rate was 7.4%. Three patients required repeat revascularization within a mean follow-up duration of 49.6 ± 36.5 months. Overall graft patency was 89.2% at 20.2 months and graft patency post-coronary endarterectomy was 85.4%. Arterial grafts showed 100% patency. Vein grafts to endarterectomized obtuse marginal branch had patency rates of 33.3%. Multiple endarterectomies were associated with worse one-year major adverse cardiac and cerebrovascular events (OR: 28.6 ± 1.16; P = 0.003).

CONCLUSIONS

Coronary endarterectomy facilitates completeness of revascularization and does not increase early mortality. Graft patency post-coronary endarterectomy on obtuse marginal artery was suboptimal. Judicious use of coronary endarterectomy should be practiced to balance the need of completeness of revascularization against the risk of myocardial infarction.

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.

Anti-coagulation therapy following coronary endarterectomy in patient with coronary artery bypass graft

Background

Since there is a lack of research on postoperative anticoagulation protocol in patients undergoing coronary artery bypass graft (CABG) / coronary endarterectomy (CE), we recommend a new protocol for anticoagulation in these patients.

Methods

In this double-blind randomized clinical trial study, 52 patients undergoing CABG / CE entered the study and were divided into two groups. In group 1, the patients were given warfarin(international normalized ratio (INR) between 2-3) together with 80 mg aspirin daily for 3 months. In group 2, the patients were given 75 mg plavix daily together with 80 mg aspirin daily for 3 months. We evaluated patients with electrocardiography, echocardiography and checking ceratin phosphokinase MB and troponin I in the several stages. The data were analysed SPSS Version18 software.

Results

There was no significant difference between pre and post-operative Ejection fraction in patients with plavix (P=0.21) and warfarin (P=0.316) regimen. However, wall mrotion score was significantly better in clopidogrel - aspirin patients in late (3 months) post operation (p<0.001).

Conclusions

Since warfarin has serious hemorrhagic complications and requires closed monitoring of serum drug activity by serial INR checking, it is recommended that clopidogrel - aspirin can be the preferred alternative anticoagulation therapy in CABG / CE patients.

Frequency of Coronary Endarterectomy in Patients Undergoing Coronary Artery Bypass Grafting at a Single Tertiary Texas Hospital 2010 to 2016 With Morphologic Studies of the Operatively Excised Specimens

This study examines the frequency of coronary endarterectomy (CE) procedures during coronary artery bypass grafting (CABG), and determines the quantity of plaque in the specimens. Of the 2,268 CABG operations performed from January 2010 to June 2016, 35 patients had CE during CABG. The specimens were incised into 5-mm cross sections, stained by the Movat method, and examined. The number of CEs performed ranged from 0.21% to 4.01%. A total of 140 cm of specimens were examined, and all 140 cm contained considerable quantities of atherosclerotic plaque and narrowed lumens. The quantity of plaque present was similar to or greater than that observed in previously studied patients with fatal coronary artery disease. The frequency of CE during CABG varies greatly in surgeons. The quantity of plaque is enormous, and the lumens are severely narrowed.

Comparing short and long term survival of patients undergoing off pump coronary artery bypass graft with and without coronary endarterectomy

Background and aim

There is some controversy about survival of coronary endarterectomy (CE) patients, so the current study aims to compare short and long term survival of patients undergoing off pump coronary artery bypass graft (OPCAB) with and without coronary endarterectomy.

Patients and methods

we performed a retrospective analysis of data on patients undergoing OPCAB and CE between 2011 and 2012. Preoperative, perioperative and postoperative data collected from data bank. Follow-up information was obtained from telephone contact mean time 37.13 ± 23.82 months after surgery. Early and late outcomes were compared by univariate and Kaplan-Meier analysis.

Result

OPCAB was performed in 474 patients, which 69 of them had a CE. The mean long term survival was similar between OPCAB (56.28 ± 0.61) and OPCAB + CE (55.54 ± 1.3) groups (p = 0.66). Multiple Cox regression shows that age, gender, BMI, EF and angina were significant predictors of mortality. Patients undergoing CE have a long term intensive care unit (ICU) stay (51.31 ± 5.59 vs 37.23 ± 0.88, P = 0.015) and blood transfusion was higher in CE group (650.62 ± 110 vs. 324.71 ± 22, P = 0.001).

Conclusion

The current study demonstrates that results of CE are acceptable with respect to short and long -term survival. Patients undergoing CE required long term ICU stay and higher blood transfusion.

Surgical Revascularization of the Left Anterior Descending Artery with Multiple Failed Overlapping Stents

BACKGROUND

Multiple stents make standard coronary artery bypass techniques difficult. We describe our surgical approach, in patients undergoing coronary artery bypass grafting (CABG), in left anterior descending arteries (LAD) with multiple failed overlapping stents.

METHODS

We retrospectively reviewed the data of six patients undergoing CABG with multiple failed overlapping stents in the LAD. All patients were operated on electively. After removal of the stents with an open endarterectomy, the long segmental arteriotomy of the LAD was reconstructed with a saphenous vein patch. Afterwards the left internal mammary artery was anastomosed to the vein patch.

RESULTS

The mean age was 61.5 ± 7.9 years. Five patients (83.3%) were in Canadian Cardiovascular Society Class III or IV. Four patients (66.6%) had suffered a remote myocardial infarction (>1 month). The average hospital stay was 6.5 ± 1.1 days. Postoperative electrocardiograms showed no specific changes and no myocardial enzyme elevations were noted. Early postoperative angiography showed that all grafts including the endarterectomized LAD were patent. There was no mortality within the 30 days. Patients' mean follow-up time was 35.6 ± 36.7 months.

CONCLUSIONS

CABG with open stent endarterectomy is a valuable alternative option for patients with "full-metal jacket" diseased LAD that are not graftable using standard surgical techniques.

Early results of coronary endarterectomy combined with coronary artery bypass grafting in patients with diffused coronary artery disease

Background:

It is still a challenge for the cardiac surgeons to achieve adequate revascularization for diffused coronary artery disease (CAD). Coronary endarterectomy (CE) offers an alternative choice of coronary artery reconstruction and revascularization. In this study, short-term result of CE combined with coronary artery bypass graft (CABG) was discussed in the treatment for the diffused CAD.

Methods:

From January 2012 to April 2014, 221 cases of CABG were performed by the same surgeon in our unit. Among these cases, 38 cases of CE + CABG were performed, which was about 17.2% (38/221) of the cohort. All these patients were divided into two groups: CE + CABG group (Group A) and CABG alone group (Group B). All clinical data were compared between the two groups, and postoperative complications and in-hospital mortality were analyzed. The categorical and continuous variables were analyzed by Chi-square test and Student's t-test respectively.

Results:

Diabetes mellitus, hypertension, hyperlipidemia, and peripheral vascular disease were more common in group A. In this cohort, a total of 50 vessels were endarterectomized. Among them, CE was performed on left anterior descending artery in 11 cases, on right coronary artery in 29 cases, on diagonal artery in 3 cases, on intermediate artery in 2 cases, on obtuse marginal artery in 5 cases. There was no hospital mortality in both groups. The intro-aortic balloon pump was required in 3 cases in Group A (3/38), which was more often than that in Group B (3/183). At the time of follow-up, coronary computed tomography angiogram showed all the grafts with CE were patent (50/50). There is no cardio-related mortality in both groups. All these patients were free from coronary re-intervention.

Conclusions:

Coronary endarterectomy + CABG can offer satisfactory result for patients with diffused CAD in a short-term after the operation.

Outcome and graft patency in coronary artery bypass grafting with coronary endarterectomy

Background

Controversy persists regarding the use of coronary endarterectomy (CE) in patients with severe coronary artery disease. We compared the comorbidities and perioperative characteristics of patients undergoing coronary artery bypass grafting (CABG) with and without CE.

Methods

This study was performed in two private hospitals in Shiraz, Iran from May 2010 to December 2011 on 967 patients who underwent CABG without CE and 84 patients who underwent CABG with CE (the CE+ group). After follow-up at 9.66±3.65 months post-surgery, 28 patients from the CE+ group underwent angiography to evaluate the patency of grafts and native coronary vessels.

Results

Patients in the CE+ group had a more prevalent history of diabetes (48% vs. 36%) and number of diseased vessels (2.88±0.39 vs. 2.70±0.85). The overall hospital mortality was 1.8%, and no significant difference was observed between the two groups. In the 28 patients who underwent reangiography, 113 vessels were bypassed and 29 endarterectomies were performed, mostly on the left anterior descending artery (12 endarterectomies) and the right coronary artery (8 endarterectomies). In the endarterectomized vessels, a 66% patency rate was found in both the grafts and the native vessels. The native coronary vessels were more likely to be patent when the left internal mammary artery was used as a conduit than when a saphenous vein bypass graft was used.

Conclusion

The lack of a significant difference in postoperative complications in patients who underwent CABG with or without CE may indicate that CE does not expose patients to a higher risk of complications. Since most of the endarterectomized vessels were shown to be patent during the follow-up period, we propose that endarterectomy is a viable option for patients with severely diseased vessels.

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.

Mid-term outcome and angiographic follow-up of endarterectomy of the left anterior descending artery in patients undergoing coronary artery bypass surgery

BACKGROUND AND AIM

With the advancement of percutaneous coronary interventions (PCIs), more patients with diffuse coronary artery disease are referred for coronary artery bypass graft (CABG) surgery. The use of coronary endarterectomy may be useful in such cases. We reviewed our experience with left anterior descending artery endarterectomy as an adjunct to conventional CABG.

METHODS

Between June 2005 and 2011, 58 consecutive patients underwent left anterior descending artery endarterectomy as an adjunct to CABG. These were matched to 58 cases based on age, gender, and Parsonnet score. All data were collected prospectively in a departmental database. Postoperative complications and in-hospital mortality were analyzed. Survival curves were produced.

RESULTS

There was one death in the endarterectomy group (1.7%) from liver failure. There was no significant difference in postoperative complications (especially perioperative myocardial infarction) between the two groups with similar hospital mortality. Computed tomography (CT) angiography was performed in 24 patients with endarterectomy (41%), which showed 100% patency of the left internal mammary artery graft to the left anterior descending artery. Survival and freedom from intervention at a mean follow-up of 4.2 years were similar.

CONCLUSIONS

In patients with diffuse disease, the use of endarterectomy is a safe technique with no increase in short-term morbidity or mortality. Mid-term results are similar to nonendarterectomized patients. This technique is useful in patients with diffuse coronary artery disease.

Long term follow up results of sequential left internal thoracic artery grafts on severe left anterior descending artery disease

PURPOSE

Several alternative procedures have been proposed to achieve complete revascularization in the presence of diffuse left anterior descending coronary artery (LAD) disease. With the extensive use of internal thoracic artery grafts in coronary artery bypass procedures, sequential anastomosis of the left internal thoracic artery (LITA) to LAD has gained popularity in these challenging cases. The long term results of sequential LITA to LAD anstomosis were examined in this study.

PATIENTS AND METHODS

In order to determine the long term results of the sequential revascularization of LAD by LITA graft, 41 out of 49 patients operated between January 2001 and December 2005 were selected for control coronary arteriography. The median period for control coronary arteriography was 64 months.

RESULTS

Seventy five anastomoses were found to be fully patent (91,46%) among the 82 sequential LITA anastomoses (41 LITA grafts) on the LAD at a median follow-up period of 64 months (53 to 123 months). Among the 41 LITA grafts used for this purpose, 36 were found intact (complete patency of the proximal and distal anastomoses) (87,8%). Two LITA grafts (4 anastomoses) were found to be totally occluded (4,87%). The proximal anastomosis of the LITA graft was observed to be 90% stenotic in one patient (1,21%). In one patient tight stenosis of the distal anastomosis line was observed (1,21%), while in another patient 70% narrowing of LITA lumen after the proximal anastomosis was detected (1,21%).

CONCLUSION

We strongly beleive that sequential LITA grafting of LAD is a safe alternative in the presence of severe LAD disease to achieve complete revascularization of the anterior myocardium with patency rates not much differing from conventional single LITA to LAD anastomosis.

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.

Long term survival after coronary endarterectomy in patients undergoing combined coronary and valvular surgery--a fifteen year experience

BACKGROUND

Coronary Endarterectomy (CE) in patients undergoing coronary artery bypass graft (CABG) surgery has been shown to be beneficial in those with diffuse coronary artery disease. There are no published data on its role and benefit in patients undergoing more complex operations. We present our experience with CE in patients undergoing valve surgery with concomitant CABG.

MATERIALS AND METHODS

Between 1989 and 2003, 237 patients underwent CABG with valve surgery under a single surgeon at our institution. Of these, 41 patients needed CE. Data was retrospectively obtained from hospital records and database. Further follow-up was obtained by telephone interview. All variables were analyzed by univariate analysis for significant factors relating to hospital mortality. Morbidity and long term survival was also studied. There were 29 males and 12 females with a mean age of 67.4 +/- 8.1 and body mass index of 26.3 +/- 3.3. Their mean euroscore was 7.6 +/- 3.2 and the log euro score was 12.2 +/- 16.1.

RESULTS

Thirty-two patients were discharged from the intensive therapy unit within 48 hours after surgery. Average hospital stay was 12.7 +/- 10.43 days. Thirty day mortality was 9.8%. Six late deaths occurred during the 14 year follow up. Ten year survival was 57.2% (95% CL 37.8%-86.6%). Three of the survivors had Class II symptoms, with one requiring nitrates. None required further percutaneous or surgical intervention. We compared the result with the available mortality figure from the SCTS database.

CONCLUSION

Compared to the SCTS database for these patients, we have observed that CE does not increase the mortality in combined procedures. By accomplishing revascularization in areas deemed ungraftable, we have shown an added survival benefit in this group of patients.

Survival and graft patency after coronary artery bypass grafting with coronary endarterectomy: role of arterial versus vein conduits

BACKGROUND

Coronary artery bypass grafting with concomitant coronary endarterectomy (CABG/CE) is used in patients with severe coronary atherosclerosis to revascularize otherwise ungraftable targets. This study investigates the efficacy of arterial versus vein grafting for CABG/CE surgery.

METHODS

We reviewed our experience in 288 CABG/CE patients (63 +/- 10 years, 207 men). A total of 1,056 grafts (275 internal thoracic artery [ITA] [26%]; 221 radial [21%], 560 vein [53%]) were constructed including 325 (31%) placed to CE targets.

RESULTS

Eighteen of 288 patients died in-hospital (6.3%). Unadjusted one-year and five-year survival for the 270 discharged patients was 95.2% and 83.0%, respectively. Survival (0 to 7 years) was significantly better for patients with radial (n = 154) versus no-radial (n = 134) artery grafting (p = 0.021). Multivariate Cox regression analysis associated increased number of arterial grafts (hazard ratio [HR] = 0.64 [0.44 to 0.92]; HR [95% confidence interval]) to improved survival, while RCA endarterectomy (HR = 1.8 1.0 3.3; p = 0.054) was associated with worse survival. Repeat angiography (495 days [median]) in 68 patients encompassed 78 CE (38 vein, 24 ITA, and 16 radial) and 162 non-CE (84 vein, 40 ITA, and 38 radial) grafts. Graft failure was similar (p = 0.37) for radial (10 of 54 [19%]) and ITA (7 of 64 [11%]), and worst for vein (50 of 122 [41%]; p < 0.001). For CE targets, graft failure was worse for vein (55% vs 35%; p = 0.05) and unchanged for arterial (13% vs 15%; p = 0.88) grafts.

CONCLUSIONS

Combined CABG/CE is associated with good long-term outcomes. Increased arterial grafting achieved by radial artery utilization confers a survival benefit in this high-risk population. The latter is probably derived from superior radial versus vein graft patency.

Long-Term Results of the Left Anterior Descending Coronary Artery Reconstruction With Left Internal Thoracic Artery

BACKGROUND

Recent refinements in percutaneous techniques have resulted in an increase in the numbers of patients with diffuse coronary artery disease who are referred to cardiac surgeons. Long-segmental reconstruction of the diffusely diseased left anterior descending (LAD) coronary artery with the left internal thoracic artery (LITA) has been shown to be beneficial for patients with diffuse coronary artery disease. In this retrospective study, we analyzed the long-term outcomes obtained with this technique.

METHODS

Between April 1997 and February 2006, 3736 coronary artery bypass grafting (CABG) operations were performed by our team. Of these cases, 524 patients (14%) with the diffusely diseased LAD underwent a long-segmental reconstruction procedure with a LITA graft.

RESULTS

The cohort consisted of 372 men (71%) and 152 women (29%), and the mean age was 56.5 +/- 8.2 years. The mean length of the arteriotomy incision was 4.5 +/- 1.2 cm (range, 2 to 10 cm). Postoperative mortality was 1.9%, and the myocardial infarction rate was 6.9%. At 3, 5, and 7 years, overall survival was 93.8% +/- 0.5%, 89.6% +/- 1.5%, and 85.5% +/- 2.6%, and actuarial freedom from angina recurrence was 94.5% +/- 1%, 88.5% +/- 2%, and 82.9% +/- 3%, respectively. Among survivors, interim angiographic evaluation was performed in 128 patients at a mean follow-up of 52.4 +/- 13.5 months, and the patency rate of the LITA-LAD anastomosis was 91.4%.

CONCLUSIONS

Patients with diffuse LAD disease present a major challenge for cardiovascular surgeons. The long-term results of long-segmental LAD reconstruction are very encouraging, and this approach may be used safely in this subgroup of patients.

Predictors of Ischemic Stroke in the Territory of a Symptomatic Intracranial Arterial Stenosis

Background— Antithrombotic therapy for intracranial arterial stenosis was recently evaluated in the Warfarin versus Aspirin for Symptomatic Intracranial Disease (WASID) trial. A prespecified aim of WASID was to identify patients at highest risk for stroke in the territory of the stenotic artery who would be the target group for a subsequent trial comparing intracranial stenting with medical therapy.

Methods and Results— WASID was a randomized, double-blinded, multicenter trial involving 569 patients with transient ischemic attack or ischemic stroke due to 50% to 99% stenosis of a major intracranial artery. Median time from qualifying event to randomization was 17 days, and mean follow-up was 1.8 years. Multivariable Cox proportional hazards models were used to identify factors associated with subsequent ischemic stroke in the territory of the stenotic artery. Subsequent ischemic stroke occurred in 106 patients (19.0%); 77 (73%) of these strokes were in the territory of the stenotic artery. Risk of stroke in the territory of the stenotic artery was highest with severe stenosis ≥70% (hazard ratio 2.03; 95% confidence interval 1.29 to 3.22; P =0.0025) and in patients enrolled early (≤17 days) after the qualifying event (hazard ratio 1.69; 95% confidence interval 1.06 to 2.72; P =0.028). Women were also at increased risk, although this was of borderline significance (hazard ratio 1.59; 95% confidence interval 1.00 to 2.55; P =0.051). Location of stenosis, type of qualifying event, and prior use of antithrombotic medications were not associated with increased risk.

Conclusions— Among patients with symptomatic intracranial stenosis, the risk of subsequent stroke in the territory of the stenotic artery is greatest with stenosis ≥70%, after recent symptoms, and in women.

Optimal Method of Coronary Endarterectomy for Diffusely Diseased Coronary Arteries

BACKGROUND

Although several techniques for coronary artery bypass grafting have been introduced that incorporate coronary endarterectomy (CE), there is little information about late patency among the various CE methods. To clarify the quality of CE, we assessed clinical and angiographic results of our experience with this procedure on 127 patients who had diffusely diseased coronary arteries.

METHODS

Between January 1994 and December 2002, 127 patients underwent coronary artery bypass grafting with CE. Sixty-eight patients undergoing CE with long arteriotomies and on-lay patch bypass grafting (group O) were compared with 59 patients undergoing CE with the conventional pull-out method (group P).

RESULTS

Thirty-day mortality was 2.9% in group O and 6.8% in group P. The early angiographic results of 115 patients revealed a patency rate of 92.1% (grade A: 79.4%) in group O and 88.6% (grade A: 68.6%) in group P. Actuarial survival at 5 years was 90.7% in group O and 74.0% in group P (p = 0.1). Angiograms performed on 78 patients after a mean period of 21 +/- 16 months showed a patency rate of 89.1% (grade A:76.1%) in group O and 81.0% (grade A: 38.1%) in group P (grade A: p < 0.001).

CONCLUSIONS

The midterm angiographic results of CE with long arteriotomies and on-lay patch bypass grafting were better than the results obtained with the conventional pull-out method. This procedure was found to be safe and effective for complete revascularization in patients with a severely and diffusely diseased coronary artery.

Left anterior descending coronary endarterectomy: Early and late results in 196 consecutive patients

BACKGROUND

With advances in percutaneous coronary interventions, many patients now referred for coronary artery bypass grafting have diffuse coronary artery disease. We undertook this retrospective study to determine whether left anterior descending (LAD) coronary endarterectomy is a safe and effective long-term adjunct to coronary artery bypass grafting in patients who cannot otherwise be completely revascularized.

METHODS

Between January 1992 and March 2000, 196 of 7,633 (2.5%) consecutive patients underwent LAD coronary endarterectomy with coronary artery bypass grafting. Median age was 67 years (range, 33 to 97 years), 101 patients (52%) had unstable angina, and 182 (93%) were in New York Heart Association class III or IV. Thirty-three patients (17%) had ongoing myocardial infarction; another 17 (9%) had myocardial infarction less than 1 month. Thirty patients (15%) required intraaortic balloon pump preoperatively and 19 (10%) were reoperations.

RESULTS

All patients underwent LAD endarterectomy with coronary artery bypass grafting to the LAD. The left internal mammary artery was grafted to the LAD in 151 patients (77%), and 46 of 151 (30%) of these required an additional vein patch to the endarterectomized bed. Concomitant valve procedures were performed in 8 (4%) patients. Overall hospital mortality was 3% (6 of 196). Perioperative myocardial infarction in the LAD territory was 3%. One-year survival was 94% (95% confidence interval, 90% to 97%), whereas 5-year survival was 74% (95% confidence interval, 66% to 80%). Freedom from cardiac events (angina, myocardial infarction, congestive heart failure, percutaneous coronary interventions) was 90% (95% confidence interval, 84% to 94%) at 1 year and 84% (95% confidence interval, 75% to 90%) at 5 years.

CONCLUSIONS

Despite the presence of diffuse coronary artery disease, coronary artery bypass grafting with LAD endarterectomy offers excellent results with very low hospital mortality and morbidity, and favorable long-term survival.

Lipid peroxidation and vitamin E in human coronary atherosclerotic lesions

BACKGROUND

We aimed to assess the oxidant/antioxidant status within the ex vivo human coronary endarterectomy samples.

METHODS

To achieve this, we measured products of lipid oxidation (malondialdehyde, 7-ketocholesterol), lipids (cholesterol, cholesteryl esters) and vitamin E in endarterectomy samples.

RESULTS

Content of malondialdehyde in the plaque ranged from 0.23 to 37.36 microg/g. Unesterified cholesterol content ranged from 0.30 to 1.94 mg/g. It was 9.04+/-4.32% of total cholesterol. Total cholesterol content ranged from 1.73 to 23.69 mg/g. Cholesteryl palmitate content ranged from 0.57 to 19.10 mg/g, which is 11.43-60.86% of the total esters (mean+/-SD 40.27+/-18.42%). Cholesteryl oleate content ranged from 0.24 to 5.76 mg/g, being 9.97-21.81% of total esters (mean+/-SD 14.35+/-4.51%). Cholesteryl linoleate content ranged from 1.05 to 8.21 mg/g, being 17.84-45.15% of total esters (mean+/-SD 30.78+/-11.69%). Cholesteryl arachidonate content ranged from 0.51 to 4.20 mg/g, which is 7.56-22.87% of total esters (mean+/-SD 14.60+/-5.60%). The cholesteryl linoleate/cholesteryl oleate ratio (CL/CO) ranged from 1.01 to 4.33. Content of 7-ketocholesterol in the plaque ranged from 0.0 to 577.5 ng/g of wet weight. The 7-ketocholesterol/total cholesterol ratio was 0.003+/-0.003% (range from 0.0% to 0.008%). The 7-ketocholesterol/unesterified cholesterol ratio was 0.024+/-0.023% (range from 0.0% to 0.066%). The plaque content of vitamin E ranged from 0.0 to 40.9 microg/g of wet weight.

CONCLUSION

The present study, comprising measurements of lipids, products of lipid peroxidation and vitamin E in 12 human coronary endarterectomy samples, lends the evidence for ongoing lipid peroxidation within an atherosclerotic lesion.

Closed endarterectomy for diffuse right coronary artery disease: early results with angiographic controls

BACKGROUND

Due to reported high morbidity and mortality, surgeons tend not to endarterectomize the diffusely diseased right coronary artery. Most prefer not to bypass this artery in such situation. We compared the endarterectomized right coronary patients with patients having total occlusion of right coronary artery not needing endarterectomy who received right coronary artery (RCA) bypass.

MATERIAL AND METHODS

Between August 1998 and May 2000, 1226 patients had coronary artery bypass grafting (CABG) at Alkan Hospital, of whom 59 had right coronary artery endarterectomy (REC) along with RCA bypass with saphenous vein graft. We compared the results of 59 RCE patients with 50 patients who underwent RCA bypass without RCE.

RESULTS

Compared with the control group, the RCE group had a higher incidence of diabetes. There were no statistically significant differences between groups for mortality and morbidity. Among postoperative variables only the cross-clamp time was longer for the RCE group (33.5 +/- 10 min vs. 27.3 +/- 8 min, p < 0.05). Surviving patients were followed for a mean period of 7 +/- 5 months. No recurrence of angina occurred during the follow-up. Control angiography at the sixth month was performed on 42 RCE patients accepting the procedure, and all grafts were found patent.

CONCLUSION

Endarterectomy for diffusely atherosclerotic right coronary artery for selected patients did not bring additional mortality and morbidity to the CABG procedure, and short term clinical and angiographic results were excellent.