Outcome of coronary endarterectomy: a case-control study

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.

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: a Case Control Study and Evaluation of Early Patency Rate of Endarterectomized Arteries

OBJECTIVE

To compare two groups of patients - the coronary endarterectomy group, with patients undergoing coronary artery bypass grafting (CABG) with coronary endarterectomy (CE), and the control group, with patients undergoing CABG without CE. We analyzed the rate of major outcomes (perioperative acute myocardial infarction [AMI], stroke, and mortality) and minor outcomes (time of cardiopulmonary bypass [CPB], time of aortic clamp, and postoperative length of hospital stay). We also determined the rates of early graft patency in patients undergoing CE.

METHODS

We reviewed a database of patients submitted to CABG, with or without associated CE, between January 2011 and June 2017. Twenty-five patients submitted to CE were compared with 201 patients submitted only to conventional surgery; the two groups presented similar preoperative characteristics and all the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II variables did not presented statistically significant difference. We considered statistically significant values of P< 0.05.

RESULTS

There was no statistically significant difference in relation to time of post-surgical hospitalization (P=0.8139), incidence of perioperative AMI (P=0.2976), stroke (P=0,2976), and mortality rate (P=1.0000), but endarterectomy was associated with longer aortic clamping time (P=0.0004) and CPB time (P=0.0030). The rate of patency evaluated in patients submitted to endarterectomy (78,95%) was compatible with that described in the literature.

CONCLUSION

In this sample, coronary endarterectomy was associated with the rate of early graft patency similar to that of the literature, with morbidity and mortality rates similar to those of conventional surgery.

A Retrospective Cohort Study on Coronary Endarterectomy Outcomes in Coronary Artery Bypass Graft Patients

Introduction: The aim of this study is to determine the outcomes following coronary endarterectomy (CE) in patients who underwent coronary artery bypass grafting (CABG) for revascularization in our hospital.

Methods: We retrospectively reviewed patients who underwent CABG over a six-month period, from November 1, 2016 to May 31, 2017 and examined their outcomes in regards to CE.

Results: A total of (n=361) CABG procedures were performed in our study period, though complete records were available for only (n=254) patients. Amongst these, (n=37) patients (14.5%) required CE. Ages ranged from 43 to 75 years for these patients, (n=7) were females and (n=30) males. Comorbidities included hypertension in (n=19) patients, diabetes in (n=12) patients and hepatitis B in (n=11) patients. The right coronary artery (RCA) was the most common artery endarterectomized (n= 15), followed by the left anterior descending (LAD) (n= 10), obtuse marginal (n= 6 patients), diagonals (n=5) and ramus (n=2). Two vessels were endarterectomized in (n=4) patients. A total of (n=9) patients had two-vessel CABG, (n=16) had three-vessel CABG and (n=8) had four-vessel CABG. The left internal mammary artery (LIMA) was used in (n=25) patients. Two patients required intra-aortic balloon pump post-operatively. All the patients had received inotropic support postoperatively in the intensive care unit (ICU). There were no reports of postoperative mortality. One patient remained in the ICU for four days postoperatively, the rest of the patients were stepped down to the ward in less than four days.

Conclusions: CE is a safe and viable option as an adjunct to CABG in long segment totally occluded vessels needing revascularization and reconstruction.

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.

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.

Off-Pump Coronary Endarterectomy in High-Risk Patients

The outcome of off-pump endarterectomy in patients with diffuse coronary artery disease and increased risk factors for cardiopulmonary bypass was reviewed. Thirty-eight procedures were carried out in 32 patients (21 men and 11 women) aged 59 to 78 years (mean, 69 years). Mean left ventricular ejection fraction was 38.6% (range, 24% – 55%). The number of grafts per patient was 2.6. The left internal mammary artery was used in 29 patients (91%). Endarterectomy was performed on the right coronary artery and its branches (18), the left anterior descending artery (15), diagonal branch (2), and the circumflex system (3). Overall operative mortality was 3.1%. Perioperative myocardial infarction occurred in 6.2%. Follow-up was complete in 30 patients (94%). The mean follow-up period was 14 ± 3.3 months. Late survival was 93%. Freedom from cardiac events that required hospital re-admission was 89%. Freedom from angioplasty of the endarterectomized vessel was 96%. These findings indicate that off-pump endarterectomy can be performed with good results in patients with diffuse coronary artery disease.

Coronary endarterectomy in left anterior descending artery combined with coronary artery bypass grafting - midterm mortality and morbidity

Introduction

Completeness of myocardial revascularization is essential in surgical treatment of coronary artery disease. The aim of this study is to determine the effectiveness of coronary endarterectomy as an adjunct to coronary artery bypass grafting (CABG) in the most difficult cases.

Material and methods

Among 1559 patients who had CABG in our department, the cases of 17 who underwent an adjunct left anterior descending endarterectomy were analyzed. All procedures were performed with median sternotomy, extracorporeal circulation and in mild hypothermia (34°C), by the same surgeon. No coronary artery endarterectomy was planned before surgery.

Results

There was no infarction or cardiac arrest during hospitalization. Only one patient required mechanical circulatory support (intra-aortic balloon counterpulsation). Each patient was contacted and investigation for major adverse cardiac and cerebrovascular events (MACCE) was performed. Eleven patients (65%) already underwent midterm clinical evaluation. There was no death, myocardial infarction or cerebrovascular incident during the entire period (mean follow-up at 15.3 months). One patient required urgent coronarography due to chest pain. No other patient had chest pain or significant deterioration of ventricular function in echocardiography.

Conclusions

Outcomes and potential indications for performing left anterior descending coronary endarterectomy as an adjunct to CABG are discussed.

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.

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.

The impact of coronary artery endarterectomy on outcomes during coronary artery bypass grafting

BACKGROUND

The impact of coronary artery endarterectomy during coronary artery bypass grafting (CABG) has been debated. We examined the early and late outcomes of CABG with endarterectomy (CE) compared to CABG alone.

METHODS

Patients undergoing isolated CABG operations from 2003 to 2008 were retrospectively reviewed. We identified 99 patients who underwent CE and 3:1 propensity matched them to 297 CABG-alone patients based upon clinical factors: Society of Thoracic Surgeons (STS) predicted risk of mortality, age, gender, year of surgery, and ejection fraction. Patient risk factors as well as short- and long-term outcomes were compared by univariate and Kaplan-Meier analysis.

RESULTS

Preoperative risk factors were similar between patients undergoing CE or CABG alone. Cross-clamp times (95.6 vs. 71.8 minutes, p = 0.0001) and perfusion times (121.8 vs. 92.7 minutes, p = 0.0001) were longer in patients undergoing CE. Operative mortality (4.0% vs. 1.3%, p = 0.112) and postoperative complications were not significantly different between groups. Patients undergoing coronary endarterectomy incurred longer ICU (75.06 vs. 48.64 hours, p = 0.001) and hospital stays (9.01 vs. 7.7 days, p = 0.034). Long-term mortality (mean follow-up = 27.7 ± 17.7 months) was equivalent despite revascularization technique (p = 0.13); however, patients undergoing CE encountered worse overall freedom from myocardial infarction (MI) (p = 0.03).

CONCLUSION

Patients undergoing CABG with coronary CE required longer ventilatory support and ICU stay yet have comparable operative mortality, major complication rates, and long-term survival to isolated CABG. Coronary endarterectomy should be considered an acceptable adjunct to CABG for patients with extensive coronary artery disease to achieve complete revascularization. 

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.

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.

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.

Coronary endarterectomy: impact on morbidity and mortality when combined with coronary artery bypass surgery

BACKGROUND

The results of coronary endarterectomy (CE) performed in addition to coronary artery bypass grafting (CABG) have been controversial. We aimed to examine the impact of CE performed in addition to CABG when compared with CABG alone in our unit.

METHODS

Patients who had CABG between January 1995 and December 2001 were included. They were divided into two groups, the CABG-only group and CABG and CE group. The following outcomes were compared: perioperative myocardial infarction, postoperative ventricular arrhythmias, cerebrovascular accident, renal impairment, and early mortality.

RESULTS

Of 5,782 patients who underwent CABG, 461 patients (8.6%) required CE in addition to CABG. There was a higher mortality and incidence of postoperative renal impairment in the group of patients who had CABG and CE, with no significant difference in other outcomes. However, the patients in the CABG and CE group had a higher incidence of male sex, previous myocardial infarctions, preoperative renal impairment, and poor left ventricular function, with longer cross-clamp and cardiopulmonary bypass times than in the CABG-only patients. Although female sex, renal impairment, nonelective surgery, impaired left ventricular function, and peripheral vascular disease were associated with increased mortality in all the patients, and use of statins and aspirin was associated with a reduction in mortality, CE was not a predictor of mortality. Furthermore, on propensity scores analysis, CE was not associated with increased mortality.

CONCLUSIONS

Coronary endarterectomy when combined with CABG seemed to be associated with a higher mortality than isolated CABG in our study groups, but this is related to comorbidities of these patients rather than the CE.

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.

Prostacyclin Reduces Incidence of Myocardial Damage After Coronary Endarterectomy

BACKGROUND

After coronary endarterectomy, patients have an increased incidence of perioperative myocardial infarction. This study was undertaken to evaluate the possible reduction of perioperative myocardial damage after coronary endarterectomy by intravenous utilization of prostacyclin.

METHODS

Elective coronary artery bypass grafting was performed in 1,190 patients with diffuse and distal coronary artery disease, in whom endarterectomy of one or more vessels was used as a treatment. All procedures were done with cardiopulmonary bypass. There were 584 patients in the prostacyclin-treated group, and 606 patients in the control group. Prostacyclin (10 ng x kg(-1) x min(-1)) was started 20 minutes before the cross-clamp removal, or at the time of rewarming, and was continued during the first 24 hours after surgery. The incidence of perioperative myocardial damage was detected by creatine kinase-MB enzyme measurement, and electrocardiographic and left ventricular function changes.

RESULTS

A significant decrease in perioperative myocardial damage was detected in the group treated with prostacyclin with respect to the control group.

CONCLUSIONS

Prostacyclin infusion initiated during revascularization and continued in the early postoperative course could be successfully employed for the prevention of thrombocyte aggregation and potentially decrease the overall incidence of significant myocardial damage after coronary endarterectomy.

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.

Does coronary endarterectomy increase the risk of coronary bypass?

BACKGROUND

With increased incidence of angioplasty and stent implantation, patients referred for coronary bypass (CABG) typically have more advanced and diffuse coronary disease. Thus, more patients may require endarterectomy in order to achieve complete revascularization. We compared our results in patients undergoing CABG with or without coronary endarterectomy.

METHODS

Between 1993 and 1999, 2372 patients underwent isolated CABG in our department. A retrospective analysis was performed to compare patients requiring coronary endarterectomy of the LAD (group 1, n = 88), endarterectomy of arteries other than the LAD (group 2, n = 143), to those not requiring endarterectomy (group 3, n = 2071). Patients undergoing CABG without the use of cardiopulmonary bypass were excluded. Group 1 had a higher incidence of proximal LAD stenosis (p = 0.001) than group 3, while group 2 had a higher incidence of peripheral vascular disease (p = 0.02), preoperative MI (p = 0.03) and LV dysfunction (p = 0.001).

RESULTS

Operative mortality was 10% in group 1 (p < 0.001) and 4% in group 2 (p = NS) compared to 3% in group 3. Incidence of perioperative MI was 12% in group 1 (p = 0.001) and 8% in group 2 (p = 0.001) compared to 2% in group 3.

CONCLUSIONS

Patients requiring endarterectomy of the LAD are at increased risk of operative mortality. This was not true for patients requiring endarterectomy of arteries other than the LAD. In both groups there was an increased risk of perioperative myocardial infarction.

Is tranexamic acid safe in patients undergoing coronary endarterectomy?

BACKGROUND

Patients undergoing coronary endarterectomy during coronary artery bypass grafting (CABG) are at increased risk of perioperative myocardial infarction due to coronary intimal disruption. Data assessing the safety of the antifibrinolytic drug tranexamic acid (TA) in patients undergoing this procedure are lacking.

METHODS

From September 1997 to December 1999, 221 patients underwent nonemergency primary CABG with endarterectomy of the right coronary artery alone in 149, the left anterior descending in 35, or both right and left anterior descending in 27. TA was administered intraoperatively to 87 patients (TA group: average total dose 62 +/- 4.4 mg/kg; range 20 to 109 mg/kg), and was not administered to 134 patients (No TA group).

RESULTS

The patient characteristics of the 2 groups were similar. In-hospital mortality consisted of 2 patients in the TA group and 4 patients in the No TA group. Perioperative myocardial infarction rates were 2% and 5% in the TA and No TA groups, respectively (p = 0.49). The relative risk for any type of perioperative cardiac ischemic event in the TA group versus the No TA group was 0.77 (95% CI; 0.4, 1.2). Patients in the TA group had a significant reduction in postoperative chest tube drainage (685 versus 894 mL in the TA versus No TA groups, respectively) and in the use of fresh-frozen plasma (p = 0.03).

CONCLUSIONS

These results suggest that the clinical effectiveness of tranexamic acid in reducing postoperative blood loss in patients undergoing coronary endarterectomy is not associated with a higher incidence of myocardial ischemia-related complications.

Long-term angiographic results of coronary endarterectomy

BACKGROUND

To evaluate the long-term patency of endarterectomized coronary vessels, we studied patients having recatheterization after coronary artery bypass grafting.

METHODS

Forty-one clinical and angiographic variables were analyzed in 97 study patients who had coronary endarterectomy (CE) and in 154 control patients who did not have CE but who had repeat catheterization after coronary artery bypass grafting.

RESULTS

Ninety-seven patients had 132 CEs. The right coronary artery was the most commonly endarterectomized vessel (73 of the 132 endarterectomized vessels). At a mean of 7.1 years of follow-up, significantly fewer bypass grafts to endarterectomized vessels were patent compared with nonendarterectomized vessels (40% of endarterectomized vessels compared with 58% of nonendarterectomized vessels in study patients and 65% in control patients, p = 0.0003). The only predictor of long-term CE graft patency is age-adjusted body surface area (p = 0.0068). Patency in grafts to nonendarterectomized vessels is diminished by hypertension (p = 0.046) and current cigarette use (p = 0.024) and improved by use of mammary artery grafting (p < 0.0001).

CONCLUSIONS

These results show that long-term patency in bypass grafts to endarterectomized vessels is less common than in nonendarterectomized vessels and that this patency is related to larger body size. Patency in nonendarterectomized vessels is reduced by risks of arteriosclerosis. This suggests that CE should be used with caution in smaller patients and that aggressive control of risk factors for atherogenesis is particularly important in patients who have CE. On the basis of these results, we speculate that the extent of disease is advanced in patients who require CE.