HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Victor A. Ferraris John D. Harrah Dennis M. Moritz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ferraris, V. A. Articles by Ferraris, S. P. Search for Related Content PubMed PubMed Citation Articles by Ferraris, V. A. Articles by Ferraris, S. P. Related Collections Related Article

Ann Thorac Surg 2000;69:1737-1743
© 2000 The Society of Thoracic Surgeons

---

Original articles: Cardiovascular

Long-term angiographic results of coronary endarterectomy

^a Department of Cardiovascular Services, Marshall University School of Medicine, Huntington, West Virginia, USA

Address reprint requests to Dr Victor Ferraris, Department of Cardiovascular Services, Marshall University School of Medicine, 341 12th Ave, Huntington, WV 25701
e-mail: ferraris{at}earthlink.net

Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.

	Abstract

Top Abstract Introduction Material and methods Results Comment Appendix References

 
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.

	Introduction

Top Abstract Introduction Material and methods Results Comment Appendix References

 
Coronary endarterectomy (CE) was one of the earliest forms of therapy used to treat myocardial ischemia. It has been used for more than 40 years to improve blood flow to severely diseased coronary arteries [1]. There is abundant information available about short-term operative outcomes after CE [2–5]. Most reports [2, 3, 5], but not all [4], suggest slightly increased perioperative morbidity and mortality associated with CE. Certain cardiac centers report acceptable results using CE to salvage high-risk, especially critically ill, patients with end-stage coronary artery disease [5, 6]. There is surprisingly little information available about the long-term patency of endarterectomized vessels [7, 8].

During the last 20 years, in a stable community, we used CE as an adjunct to complete coronary revascularization. Endarterectomy was used in as many as 10% of patients, commonly in those patients with complex coronary artery obstructions, especially totally occluded vessels. Hence, we have access to a large, rather localized, population of patients who had CE. A subset of this population had cardiac catheterization at various times after coronary operations in which endarterectomy was used. In an effort to expand our knowledge about the long-term patency of endarterectomized coronary vessels, we reviewed the results of recatheterization in this population. For comparison, we reviewed the results of catheterization in a control population in which endarterectomy was not used. Our results suggest that bypass grafts to endarterectomized vessels have diminished patency compared with control vessels. Factors associated with decreased patency of grafts to endarterectomized vessels are presented.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Appendix References

 
Patient selection
A historical cohort study of patients having CE was undertaken. Patients having cardiac catheterization were reviewed beginning in December 1998 and extending back for a 9-year period until 100 patients who had previous CE were identified (study patients). For each 2 study patients, an attempt was made to obtain 3 control patients. Patients undergoing recatheterization who did not have CE at their original operation were used as a control population (control patients). The control patient immediately before or immediately after each study patient was added to the nonendarterectomized control cohort. Using this sampling method, 154 control patients were studied. Forty-one clinical and angiographic variables were studied by reviewing the hospital charts of each patient in the cohort. Three control and 3 study patients were eliminated from the final cohort because of incomplete data.

Patient variables
Three types of patient variables were measured: demographic data, patient comorbidities, and intraoperative variables. Demographic data included age, sex, and indicators of body size. Patient comorbidities studied included risks for arteriosclerosis, such as diabetes, cigarette use, and hypertension, as well as evidence of prior noncardiac organ system dysfunction, such as chronic obstructive lung disease, renal dysfunction, peripheral vascular disease, and cerebral vascular disease. Intraoperative variables evaluated included number of vessels bypassed at initial operation, as well as operative times and type of conduit used for bypass.

Surgical technique of coronary endarterectomy
Coronary artery bypass grafting with cardiopulmonary bypass was performed using standard methods. This included hypothermic cardiac arrest using intermittent cold crystalloid cardioplegia solution and aortic root venting. Proximal anastomoses were performed with the aorta partially occluded. Typically, the endarterectomized vessel was totally occluded proximally with a small vessel caliber distally. The techniques used for CE were similar to those published by Mills [9]. Endarterectomy was performed both proximally and distally from the site of arteriotomy. As much plaque as possible was removed, typically between 4 and 10 cm. After removing the endarterectomy specimen, the vessel was flushed sequentially with dilute dextran solution followed by blood. If blood did not fill the distal artery, then distal coronary artery bypass grafting was performed. Patients were given coumadin for 3 months after undergoing CE.

Statistical methods
The long-term patency of bypass grafts to both endarterectomized and nonendarterectomized vessels was summarized using Kaplan-Meier estimates [10]. The bypass graft survival for endarterectomized vessels and nonendarterectomized vessels were compared using the log-rank test. Graft survival time was assumed to be the time from operation to recatheterization if the vessels were totally occluded or had more than 75% cross-sectional stenosis. If vessels had less than 75% stenosis, survival times were considered censored for purposes of survival analysis.

Cox regression analysis with interval-censoring was used to determine variables predictive of endarterectomy patency [11]. It is necessary to use interval-censoring because the exact failure time of bypass grafts to endarterectomized vessels is not known, but the failure time is known to have occurred during a particular interval of time. The rationale for using interval-censoring is as follows. Suppose that endarterectomized and nonendarterectomized vessels have exactly the same survival but that, for some reason, endarterectomy has the effect of suppressing symptoms. Interval-detected graft failures will be identified sooner in nonendarterectomized vessels, even though there is no difference in survival of the grafts. For this reason, it is necessary to account for the effect of sampling of survival times at different intervals.

The bypass graft survival data for control and study patients were divided into two intervals. The first interval included patients who underwent recatheterization within 24 months of operation. This interval is likely to have some physiologic significance as it is less likely that arteriosclerosis is the cause of graft failure. Patients evaluated within 24 months of operation were considered short-term interval-detected patients. Patients who had recatheterization more than 24 months after operation were considered long-term patients.

	Results

Top Abstract Introduction Material and methods Results Comment Appendix References

 
Patient characteristics
There were no significant differences between study and control patients with respect to age, body size, or sex (Table 1). Likewise, patient comorbidities were similar in both study and control patients. Peripheral vascular disease was slightly more common in patients who had CE, but not significantly so (Table 2).

View larger version (26K): [in this window] [in a new window]   Fig 1. Interval between operation and recatheterization (recath).

Graft survival
Kaplan-Meier estimates were constructed for graft patency in study and control patients. Separate survival estimates for bypass grafts to endarterectomized and nonendarterectomized vessels in study patients were constructed (Fig 2). Bypass grafts to endarterectomized vessels had significantly decreased survival compared with either nonendarterectomized vessels in control patients or nonendarterectomized vessels in study patients. Significant differences between bypass grafts to nonendarterectomized and to endarterectomized vessels are particularly pronounced beginning at approximately 100 months after operation.

View larger version (23K): [in this window] [in a new window]   Fig 2. Kaplan-Meier survival estimates for control and study vessels. (CE = coronary endarterectomy.)

Interval-censored Cox survival analysis was used to determine risk factors for failure of bypass grafts to nonendarterectomized vessels (Table 5). Risks for failure of grafts to nonendarterectomized vessels are hypertension (p = 0.046), current smoking (p = 0.045), failure to use the left internal mammary artery as a bypass conduit (p < 0.0001), and the interval between operation and recatheterization (p < 0.0001).

	Comment

Top Abstract Introduction Material and methods Results Comment Appendix References

 
Our results suggest that long-term patency of bypass grafts placed to endarterectomized coronary arteries is diminished compared with those used to bypass nonendarterectomized vessels. This result has intuitive appeal and is supported by other observations [3–7, 12]. As is typical of many retrospective studies, more questions are raised than are answered. What follows is a discussion of questions raised by these results.

Do coronary endarterectomy patients have more advanced disease?
The patency of bypass grafts to nonendarterectomized vessels in endarterectomy patients is diminished compared with nonendarterectomized vessels in control patients. This supports the notion that CE patients have advanced disease. Most authors who have written about CE as an adjunct to coronary revascularization concede that CE is only used for complex reconstructions or for patients with end-stage coronary artery disease. This suggests that there is significant bias in selection of CE patients. There is no difference between endarterectomy patients and nonendarterectomy patients with regard to comorbidities or demographics (Tables 1 and 2). Yet, most of the arteries that were subjected to endarterectomy were completely occluded. The fact that CE patients required significantly more bypass grafts (Table 3) and are likely to have more totally occluded vessels provides indirect evidence that CE patients have more advanced disease compared with non-CE patients. There is a strong suggestion that patients who require CE have far-advanced, complex disease, but there are only limited objective data to confirm this supposition.

Is anticoagulation necessary after coronary endarterectomy?
We routinely place CE patients on warfarin therapy for 2 to 3 months after operation. Postoperative warfarin therapy has associated risks and usually prolongs hospitalization, although adequate anticoagulation is achieved. Are the potential risks of warfarin offset by benefits in patency of CE vessels? The milieu within the coronary artery after endarterectomy is analogous to that after percutaneous interventions and in acute coronary syndromes. Several studies document that more than aspirin alone is required to maintain long-term patency in culprit vessels in the setting of disturbed coronary endothelium [13, 14]. There is no reason to suppose that the situation in endarterectomized coronary vessels is much different from that in the coronary artery after percutaneous transluminal coronary angioplasty or in acute coronary artery syndromes. Furthermore, thrombin is necessary for the formation, growth, maintenance, and consolidation of thrombus in injured vessels [15]. Because aspirin has little direct antithrombin effect, it is reasonable to add an antithrombin drug, such as warfarin, to the regimen after CE. For these reasons we believe that the risk and added expense of warfarin therapy is justified in patients who have CE.

Is graft survival related to coronary endarterectomy technique?
Many technical variations have been proposed for the performance of CE [16–18]. These include injecting cardioplegia into the plane of endarterectomy [18], use of carbon dioxide to elevate the flap in the endarterectomy plane [16], and use of a distal vein patch and proximal internal mammary artery grafting [17]. Most authors do not use these adjunctive techniques and advocate direct CE with or without a saphenous vein patch. All of the endarterectomies in study patients were performed in this manner. Little information in our study relates to technical issues, but Keogh and coauthors [19] used angioscopy to evaluate intravascular morphology after CE. They found intimal flaps or truncation of side branches in several of the endarterectomized vessels. This suggests that technical considerations may be important in long-term results of CE. Mills [9] reviewed the technical aspects of CE and concluded that technical issues are important for successful endarterectomy; in particular, instruments of appropriate size and design play a role in achieving satisfactory endarterectomy. It is likely that technical issues play a role in long-term patency of endarterectomized vessels.

Is body size the only determinate of long-term patency of coronary endarterectomy?
Many studies [20, 21], but not all [22, 23], conclude that smaller body size is an independent predictor of poor outcome after coronary artery bypass grafting. Traditionally, smaller body size has been associated with smaller lumen diameter in coronary arteries [20, 21]. O’Connor and coworkers [21] found that mid left anterior descending coronary artery diameter correlates both with body size and with operative mortality after coronary revascularization. In our study, a surprising finding was that the only determinant of patency of bypass grafts to endarterectomized vessels was body surface area. Smaller body surface area did not correlate with decreased graft patency in nonendarterectomized vessels. These results suggest that the association of a small body size and endarterectomized vessel combine to cause both early and late graft occlusion. Certain morphologic and biochemical properties in endarterectomized vessels undoubtedly play a role in vessel obstruction occurring more commonly in smaller vessels than in larger ones. The exact mechanism of this process is unknown. Likewise, other variables responsible for this effect undoubtedly exist but were not measured in the present study.

Study shortcomings
This study contains several shortcomings. First, it is a retrospective study with all of the biases of any such study. There are likely to be subtle differences that caused the surgeon to do an endarterectomy as opposed to a more conventional coronary artery bypass grafting procedure. These subtle differences cannot be gleaned by review of the chart. In support of this concept is the fact that the study patients had decreased long-term patency in bypass grafts to the nonendarterectomized vessels compared with nonendarterectomized vessels in control patients (Fig 2). This suggests that study patients may have more severe disease at baseline compared with control patients. Even though endarterectomy patients are likely to have more severe disease than control patients, our results comparing patency in bypass grafts to nonendarterectomized versus endarterectomized vessels in the same patient suggest that endarterectomy itself is associated with decreased long-term patency.

There is an obvious selection bias incorporated into the results. Only patients who survived to recatheterization were studied. In addition, patients who were alive and well were not studied. Many patients who had endarterectomy were not included in this study. It is not clear whether the patients sampled in the study group represent a random sample of all patients who had endarterectomy. The use of control patients in the cohort study and the comparison with nonendarterectomized vessels in study patients attempt to minimize this obvious selection bias. Nonetheless, some uncertainty remains.

Finally, assumptions were made to be able to use interval-censored survival analysis. All of these assumptions may not be applicable for our data set. It is interesting that the analysis that accounts for interval-censoring gives similar results to the analysis performed in the conventional manner using Cox regression without interval-censoring.

In spite of these shortcomings, we believe that there is not an easy way to answer questions about long-term patency of grafts to endarterectomized vessels and this study offers potentially useful insights.

Speculations
On the basis of these results, several postulates about CE can be made. It is logical to assume that bypass grafts to endarterectomized vessels will have decreased patency compared with nonendarterectomized vessels. Still, some perfusion is better than no perfusion when it comes to the coronary circulation. In dealing with complex coronary revascularizations, the surgeon is often faced with a choice between bypass of a very small caliber vessel that is totally occluded proximally or endarterectomy of the proximal vessel. It is a matter of surgeon’s preference as to which of these options to pursue, but our results suggest that endarterectomized vessels can have prolonged patency. This is a case of a negative result (ie, decreased patency of endarterectomy) being better than no result at all (ie, not bypassing a totally occluded vessel). Our results do not lead us to view CE in a negative light. Rather, it seems reasonable to have CE in the surgeon’s armamentarium.

Our results suggest a few cautionary notes that can guide the surgeon in dealing with these complex revascularization dilemmas. First, patients with smaller body size and older age are not the best candidates for CE, because short-term failures are more likely in this group. Second, control of risk factors for arteriosclerosis is particularly important in patients who have CE, because long-term patency depends on risks for atherogenesis. These clinical guidelines help the surgeon’s decisions in dealing with revascularization in diffusely diseased vessels.

	Appendix

Top Abstract Introduction Material and methods Results Comment Appendix References

 
In survival studies in which the exact time of failure is not known, but is known to have occurred within a certain interval, then interval-censored survival analysis is the appropriate means of analyzing the data. Interval-censored data commonly arise in studies in which there is a nonlethal end point. The following is a description of the interval-censored Cox survival analysis used in this study.

Suppose patients are followed up to time t_s, at which time catheterization is performed. Information on whether or not an occlusion of a bypassed vessel at any time up to and including the time of catheterization is then recorded. Using Cox proportional hazards model, the hazard of a recurrence at t_s for the ith patient is

where h₀(t_s) is the baseline hazard function at t_s and _i is the linear sum of the predictor variables multiplied by their coefficients. In other words:

The probability that the ith individual experiences a graft failure after time t_s is the survivor function S_i(t_s), and the survivor function is related to the predictor variables by the following equation:

where S₀(t_s) is the value of the survivor function at t_s for an individual for whom all predictor variables are zero. The probability of a recurrence up to time t_s is

By doing some algebra to the above expression, the result is

Let ß₀ = log {-log S₀(t_s)}, then a model for the survival probability can be expressed as follows:

((1))

The above equation is a linear model for the complementary log-log transformation of the probability of a recurrence up to time t_s. Now t_s represents the interval chosen for examination of patency of the grafted vessels, both endarterectomized and nonendarterectomized.

Equation 1 represents a statistical model that can be fitted to data on a binary response variable (ie, bypass graft is either patent or obstructed). The maximum likelihood function can be obtained for the model in equation 1. Models fitted to data in this manner can be compared using the statistic -2 log L, where L is the maximized likelihood of the binary data, and -2 log L is known as the deviance. The deviances for different models can be compared using the ² statistic. Table 6 lists the deviances for some of the variables in the binary response models for patency of bypass grafts to endarterectomized vessels. The variable labeled Period is a binary variable with value equal 0 if catheterization was performed at 24 months or less after operation or 1 if it was performed at more than 24 months after operation. In this interval-censored survival analysis, patency of endarterectomized vessels only depends on body surface area indexed for age (BSA).

	References

Top Abstract Introduction Material and methods Results Comment Appendix References

1. Bailey C., May A., Lemmon W. Survival after coronary endarterectomy in man. JAMA 1957;164:641-646.
2. Asimakopoulos G., Taylor K.M., Ratnatunga C.P. Outcome of coronary endarterectomy. Ann Thorac Surg 1999;67:989-993.[Abstract/Free Full Text]
3. Tasdemir O., Kiziltepe U., Karagoz H.Y., Yamak B., Korkmaz S., Bayazit K. Long-term results of reconstructions of the left anterior descending coronary artery in diffuse atherosclerotic lesions. J Thorac Cardiovasc Surg 1996;112:745-754.[Abstract/Free Full Text]
4. Christakis G.T., Rao V., Fremes S.E., Chen E., Naylor C.D., Goldman B.S. Does coronary endarterectomy adversely affect the results of bypass surgery?. J Card Surg 1993;8:72-78.[Medline]
5. Johnson W.D., Brenowitz J.B., Kayser K.L. Factors influencing long-term (10-year to 15-year) survival after a successful coronary artery bypass operation. Ann Thorac Surg 1989;48:19-24.[Abstract/Free Full Text]
6. Keon W.J., Masters R.G., Koshal A., Hendry P., Farrell E.M. Coronary endarterectomy. An adjunct to coronary artery bypass grafting. Surg Clin North Am 1988;68:669-678.[Medline]
7. Dagenais F., Cartier R., Farinas J.M., Leclerc Y., Hudon G. Coronary endarterectomy revisited. Can J Cardiol 1998;14:1121-1125.[Medline]
8. Kay P.H., Brooks N., Magee P., Sturridge M.F., Walesby R.K., Wright J.E. Bypass grafting to the right coronary artery with and without endarterectomy. Br Heart J 1985;54:489-494.[Abstract/Free Full Text]
9. Mills N.L. Coronary endarterectomy. Adv Card Surg 1998;10:197-227.[Medline]
10. Kaplan E.L., Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1957;53:457-481.
11. Collett D. Interval-censored survival data. In: Collet D., ed. Modelling survival data in medical research. London: Chapman & Hall, 1994:237-251.
12. Sommerhaug R.G., Wolfe S.F., Reid D.A., Lindsey D.E. Early clinical results of long coronary arteriotomy, endarterectomy and reconstruction combined with multiple bypass grafting for severe coronary artery disease. Am J Cardiol 1990;66:651-659.[Medline]
13. Low-molecular-weight heparin during instability in coronary artery disease, Fragmin during Instability in Coronary Artery Disease (FRISC) study group. Lancet 1996;347:561–8.
14. Cohen M., Adams P.C., Parry G., et al. Combination antithrombotic therapy in unstable rest angina and non-Q-wave infarction in nonprior aspirin users. Primary end points analysis from the ATACS trial. Antithrombotic Therapy in Acute Coronary Syndromes Research Group. Circulation 1994;89:81-88.[Abstract/Free Full Text]
15. Wysokinski W., McBane R., Chesebro J.H., Owen W.G. Reversibility of platelet thrombosis in vivo. Quantitative analysis in porcine carotid arteries. Thromb Haemost 1996;76:1108-1113.[Medline]
16. Barmada B., Diethrich E.B. Gas endarterectomy with distal bypass of the coronary arteries. Heart Lung 1975;4:397-401.[Medline]
17. Aranki S.F. A modified reconstruction technique after extended anterior descending artery endarterectomy. J Card Surg 1993;8:476-482.[Medline]
18. Harrer J., Záek P., Lonský V., et al. Contribution to technique of endarterectomy of the right coronary artery. Acta Medica (Hradec Kralove) 1996;39:155-158.[Medline]
19. Keogh B.E., Bidstrup B.P., Taylor K.M., Sapsford R.N. Angioscopic evaluation of intravascular morphology after coronary endarterectomy. Ann Thorac Surg 1991;52:771-772.
20. Fisher L.D., Kennedy J.W., Davis K.B., et al. Association of sex, physical size, and operative mortality after coronary artery bypass in the Coronary Artery Surgery Study (CASS). J Thorac Cardiovasc Surg 1982;84:334-341.[Abstract]
21. O’Connor N.J., Morton J.R., Birkmeyer J.D., Olmstead E.M., O’Connor G.T. Effect of coronary artery diameter in patients undergoing coronary bypass surgery. Northern New England Cardiovascular Disease Study Group. Circulation 1996;93:652-655.[Abstract/Free Full Text]
22. Nishida H., Nakajima M., Ihashi K., et al. Effects of smaller physical size on complex arterial grafting in coronary artery operations. Ann Thorac Surg 1996;62:733-736.[Abstract/Free Full Text]
23. Christakis G.T., Weisel R.D., Buth K.J., et al. Is body size the cause for poor outcomes of coronary artery bypass operations in women?. J Thorac Cardiovasc Surg 1995;110:1344-1348.[Abstract/Free Full Text]

This article has been cited by other articles:

				A. R. Abid, A. Farogh, M. S. Naqshband, R. P. Akhtar, and J. S. Khan Hospital Outcome of Coronary Artery Bypass Grafting and Coronary Endarterectomy Asian Cardiovascular and Thoracic Annals, February 1, 2009; 17(1): 59 - 63. [Abstract] [Full Text] [PDF]

				E. Gongora and T. M. Sundt III Myocardial Revascularization with Cardiopulmonary Bypass , January 1, 2008; 3(2008): 599 - 632. [Full Text]

				T. A. Schwann, A. Zacharias, C. J. Riordan, S. J. Durham, A. S. Shah, and R. H. Habib Survival and Graft Patency After Coronary Artery Bypass Grafting With Coronary Endarterectomy: Role of Arterial Versus Vein Conduits Ann. Thorac. Surg., July 1, 2007; 84(1): 25 - 31. [Abstract] [Full Text] [PDF]

				T. N. Ogus, M. Basaran, O. Selimoglu, T. Yildirim, H. Ogus, H. Ozcan, and M. H. Us Long-Term Results of the Left Anterior Descending Coronary Artery Reconstruction With Left Internal Thoracic Artery Ann. Thorac. Surg., February 1, 2007; 83(2): 496 - 501. [Abstract] [Full Text] [PDF]

				S. E. Kasner, M. I. Chimowitz, M. J. Lynn, H. Howlett-Smith, B. J. Stern, V. S. Hertzberg, M. R. Frankel, S. R. Levine, S. Chaturvedi, C. G. Benesch, et al. Predictors of Ischemic Stroke in the Territory of a Symptomatic Intracranial Arterial Stenosis Circulation, January 31, 2006; 113(4): 555 - 563. [Abstract] [Full Text] [PDF]

				H. Nishi, S. Miyamoto, S. Takanashi, H. Minamimura, T. Ishikawa, Y. Kato, and Y. Shimizu Optimal Method of Coronary Endarterectomy for Diffusely Diseased Coronary Arteries Ann. Thorac. Surg., March 1, 2005; 79(3): 846 - 852. [Abstract] [Full Text] [PDF]

				S R Messe, S E Kasner, Z Mehta, C P Warlow, P M Rothwell, and for the European Carotid Surgery Trialists Effect of body size on operative risk of carotid endarterectomy J. Neurol. Neurosurg. Psychiatry, December 1, 2004; 75(12): 1759 - 1761. [Abstract] [Full Text] [PDF]

				J. G. Byrne, A. N. Karavas, T. Gudbjartson, M. Leacche, J. D. Rawn, G. S. Couper, R. J. Rizzo, L. H. Cohn, and S. F. Aranki Left anterior descending coronary endarterectomy: Early and late results in 196 consecutive patients Ann. Thorac. Surg., September 1, 2004; 78(3): 867 - 873. [Abstract] [Full Text] [PDF]

				Y. J. Woo and T. J. Gardner Myocardial Revascularization with Cardiopulmonary Bypass , January 1, 2003; 2(2003): 581 - 607. [Full Text]

				F. Santini, G. Casali, M. Lusini, A. D'Onofrio, E. Barbieri, G. Rigatelli, G. Franco, and A. Mazzucco Mid-term results after extensive vein patch reconstruction and internal mammary grafting of the diffusely diseased left anterior descending coronary artery Eur J Cardiothorac Surg, June 1, 2002; 21(6): 1020 - 1025. [Abstract] [Full Text] [PDF]

				K.M. Cherian, M. Ajit, and N. Madhu Sankar The role of endarterectomy and TMR in diffuse coronary artery disease Ann. Thorac. Surg., September 1, 2001; 72(3): 976 - 977. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Victor A. Ferraris John D. Harrah Dennis M. Moritz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ferraris, V. A. Articles by Ferraris, S. P. Search for Related Content PubMed PubMed Citation Articles by Ferraris, V. A. Articles by Ferraris, S. P. Related Collections Related Article