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Ann Thorac Surg 2005;79:846-852
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Optimal Method of Coronary Endarterectomy for Diffusely Diseased Coronary Arteries

^a Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka
^b Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Chiba, Japan

Accepted for publication June 16, 2004.

^* Address reprint requests to Dr Nishi, Department of Cardiovascular Surgery, Osaka City General Hospital, 2–13–22, Miyakojimahondori, Miyakojima-ku, Osaka, 534–0021, Japan (E-mail: nishi24{at}jc4.so-net.ne.jp).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
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.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
The progressive application of noninvasive methods to achieve myocardial revascularization has contributed to the selection of patients with distinctly less attractive anatomic substrates for surgery. With recent advances in percutaneous catheter intervention such as stents, the results of percutaneous catheter intervention are now improving, and some reports show the same mortality for multivessel disease with percutaneous catheter intervention and coronary artery bypass grafting [1]. Moreover, the lesions of coronary arteries treated surgically have become more severe [2], and the population referred for revascularization is increasingly characterized by advanced age and coexisting diabetes mellitus and lipid disorders [3]. Several studies indicate that patients with a diffusely diseased coronary artery in whom standard coronary artery bypass grafting techniques cannot be performed constitute 0.8% to 25.1% of all patients with coronary artery disease [4–7]. Coronary endarterectomy (CE) was first described by Baily and associates, in 1957 [8], as a method of treating coronary artery disease without using cardiopulmonary bypass and coronary artery bypass grafting. This procedure was reported to have high postoperative morbidity and mortality during the 1960s and 1970s [9, 10]; as a result, CE came under scrutiny and its feasibility was controversial [6]. However, with the recent trend of treating more cases of diffuse coronary artery disease, increasingly indicated surgical therapy for severe and diffuse coronary artery disease has resulted in a revival of interest in CE [3, 11–19]. In an effort to expand surgical options for these patients, several techniques have been introduced, including CE and different methods for reconstructing endarterectomized vessels [11, 13, 15, 18]. However, there is little information available about the angiographic results of endarterectomized vessels [14, 15, 18].

In 1994, we introduced this method as an adjunct to coronary artery bypass grafting and have been developing and evaluating it angiographically for 10 years. To clarify the optimal method of CE, we reviewed the results of recatheterization in our experience with 127 patients who had diffusely diseased coronary artery necessitating coronary artery bypass grafting with CE.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Study Population
This study includes 127 patients with diffusely diseased coronary artery requiring operation for myocardial revascularization between January 1994 and April 2003 at Osaka City General Hospital. The mean age of the patients was 63.8 ± 8.8 years, and 34 patients (27%) were women. Two patients (2%) had single-vessel coronary artery disease, 20 patients (16%) had two-vessel disease, and 105 patients (83%) had three-vessel disease. The mean number of distal anastomoses was 4.2 ± 1.2. Coronary endarterectomy was performed in 148 branches, including 71 left anterior descending arteries (LAD), 7 diagonal arteries, 17 left circumflex arteries, and 53 right coronary arteries. The institutional ethics committee approved this technique, and the patients signed an informed consent before surgery.

The 127 patients were divided into two groups according to the operative method for coronary endarterectomy. Group P, who underwent CE by the conventional pull-out method, included 59 patients. Group O, which required long arteriotomy and on-lay patch grafting of the endarterectomized vessels, numbered 69 patients.

Angiographic Protocol
All surviving patients were requested for postoperative catheterization at 1 month, 1 year, and 5 years after the operation. Postangiographic control was obtained if the patients agreed to the procedure. The quality of the anastomosis was graded according to the classification of Fitzgibbon and colleagues [20]. Briefly, grade A stands for excellent graft patency, grade B for graft stenosis of greater than 50%, and grade O for occlusion. String sign, which was defined as a severe and extensive narrowing of the whole body of the graft, was classified as grade B anastomosis. The criterion for diagnosing perioperative myocardial infarction is defined as the maximum level of postoperative creatine kinase myocardial band greater than 100 IU/L.

Surgical Technique for Coronary Endarterectomy
Coronary artery bypass grafting was performed during cardiopulmonary bypass with normothermia (35°C). Myocardial protection was achieved by induction of antegrade and retrograde intermittent cold crystalloid cardioplegic solution. Coronary endarterectomy was applied in patients having a primary proximal significant lesion of the major coronary artery but with a diffusely diseased or calcified coronary artery, often with involvement of the distal portion, which was considered not to be amenable to other more conventional bypass grafting. Vessels undergoing CE were arteries supplying viable myocardium and had many segmental narrowings, so that anastomosing one segment would not adequately revascularize the territory of that vessel. Most of the CE was scheduled before operation, but the final decision of applying which technique was made during the operation according to the surgeon's preference.

The pull-out method (group P) was simple, as described previously [21]. A short arteriotomy was made, and the closed traction method was applied in a manner that included the proximal and distal branches. Then, bypass grafting was performed to the arteriotomy. For removing as much plaque as possible, two or three arteriotomies were sometimes made distally to pull out more atheromatous core. Bypass grafting was anastomosed to the most proximal arteriotomy, and the others were closed with a patch.

In group O, the long arteriotomy was extended until nondiseased arterial lumen was reached. The coronary artery at the level of the first major proximal lesion was neither opened nor reconstructed to avoid competitive flow between the bypass graft and the native coronary artery. Coronary endarterectomy was routinely performed through an extended arteriotomy, permitting extraction of material from the origins of septal perforators and diagonal branches under direct vision. After fixing the distal coronary artery intima, on-lay patch anastomosis using the internal thoracic artery (ITA) or saphenous vein graft was constructed over the arteriotomy, with a running suture so that the graft wall made up most of the reconstructed vessel.

Patients received anticoagulation postoperatively. Low-molecular-weight heparin was initiated 6 hours after arrival in the intensive care unit. After 2 days, this was replaced by warfarin sodium and aspirin and continued indefinitely, maintaining an international normalized ratio of 2.0.

Data Analysis and Follow-Up
Late follow-up information was obtained by postal questionnaire or telephone interview between April 1, 2003, and June 1, 2003. Three patients were lost to follow-up, for a follow-up rate of 97.6%; mean follow-up time was 52 ± 31 months (range, 5 to 109 months). All continuous variables are presented as mean ± standard deviation. Basic methods of univariate analysis included the ² test and Student's t test. Actuarial estimates of morbid events were calculated by the Kaplan-Meier survival analysis method and compared with log-rank tests. Values of p less than 0.05 were considered significant. StatView version 5.0 (SAS Institute, Cary, NC) was used for statistical analysis.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Patient Demographics
Between group O and group P there were no significant differences in terms of patient characteristics, coronary risk factors, preoperative comorbidities, or cardiac profiles (Table 1). In group P, CE was performed in 76 branches, including 24 LAD, 5 diagonal arteries, 10 left circumflex arteries, and 37 right coronary arteries. In group O, the sites of the CEs were LAD in 47, left circumflex arteries in 7, right coronary arteries in 16, and diagonal arteries in 2 cases. The mean length of on-lay patch bypass grafting was 4.9 ± 2.1 cm. The pull-out method tended to be most frequently performed for grafting to the right coronary arteries. To the LAD, on-lay patch grafting was the more frequent method of CE.

View larger version (9K): [in this window] [in a new window]   Fig 1. Actuarial estimates of survival after coronary endarterectomy with two different techniques. Group O = on-lay patch bypass grafting; Group P = pull-out method. (Pts. = patients.)

Angiographic Study
Early angiographic control was obtained in 60 patients (95%) with 63 anastomoses of endarterectomized vessels in group O and in 55 patients (93%) with 70 anastomoses in group P (Table 4). Most of the grafts in group O had a lumen with an acceptable width that did not have ectatic or narrow segments that would result in poor flow characteristics (Fig 2A). In the early angiographic results, the grafts in group P also demonstrated acceptable width (Fig 3A).

View larger version (107K): [in this window] [in a new window]   Fig 2. (A) Coronary angiography at 1 month in a patient with a 4.5-cm long endarterectomy and on-lay patch bypass grafting of the internal thoracic artery to the left anterior descending coronary artery. Regular walls and a lumen with an acceptable width can be observed. (B) The reconstruction site became smoother and still preserved a lumen with an acceptable width 41 months after the operation. Good filling of septal perforators is also noticeable.

View larger version (128K): [in this window] [in a new window]   Fig 3. (A) Coronary angiography of a patient undergoing the conventional pull-out method of carotid endarterectomy, at the early postoperative stage. The lumen at the endarterectomy and reconstruction site is irregular and patulous. (B) The reconstruction site became irregular and showed string signs 30 months after the operation.

In 21 patients of the conventional group (group P), bypass grafting was anastomosed to the most proximal arteriotomy, and the rest were closed with a patch. Early term and midterm graft patency rate in that group were 86.3% and 69.2%, respectively. On the other hand, early term and midterm graft patency rate in the rest of group P were 92.3% and 83.3%, respectively.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
The results of this study indicate that CE can be carried out with an acceptable operative risk, especially when long arteriotomies and on-lay patch bypass grafting is used as a CE method. There are several reasons for better results with the on-lay patch method. First, CE can be performed under direct vision with a long arteriotomy, exposing the whole arterial lumen and side branches containing atherosclerotic occlusive material, so that it becomes possible to avoid residual material in the lumen as well as in the dissections. Second, on-lay patch grafting of the ITA consists of new coronary lumen. We made the on-lay patch technique so that the ITA wall makes up 80% of the reconstructed vessel, and the newly reconstructed coronary artery retains 20% of the native coronary artery. Coronary artery reconstruction is performed by covering the arteriotomy with an ITA in such a fashion as to exclude atheromatous plaques from the lumen of the coronary arteries. As previously reported, once CE is performed, the resulting lack of endothelium exposes to the flowing blood all the subendothelial material that can trigger the coagulation cascade [11, 13, 22]. Although an incomplete endothelial covering of the endarterectomized arterial wall enhances myocyte proliferation, it is stopped when the endothelial covering is complete. Our technique of on-lay patch grafting reduced the endarterectomized area and presented new coronary artery wall. This might achieve rapid complete endothelial covering and should decrease the risk of intimal proliferation. The third reason is the function of the ITA. This provides better vasomotor function, particularly the capacity to adjust the flow rate in proportion to the distal runoff, a widely known paracrine function of living endothelium that produces and releases prostacyclin and other endothelium-dependent relaxation factors [23]. The diameter of the coronary artery is also important. The reconstructed segment in endarterectomy is often wider than the native artery and this depends on both the grafting technique and the graft material [11]. In cases of both saphenous vein patch reconstruction and ITA grafting, inadequate flow through the graft (associated with an irregular and patulous vein patch) was reported [18]. Our technique of CE using ITA on-lay patch can provide a better match in diameter with the graft, the reconstructed segment, and the native coronary artery, resulting in better flow patterns.

In the previous study, early postoperative mortality after CE was reported to be higher than for simple coronary artery bypass grafting [3, 11–19]. Although early mortality has improved with recent advances in CE techniques (to between 1.2% and 10.1%), it still remains higher because of the more advanced coronary artery disease that it treats [17]. Most authors report that CE is only used for complex reconstructions or for patients with end-stage coronary artery disease, and that CE patients required more bypass grafts [3, 13, 16, 17]. This suggests that there is a significant bias in the selection of CE patients. The fact that CE patients have far-advanced, complex disease must be considered. Thus, the early postoperative mortality in our series was acceptable, especially in the case of on-lay patch reconstruction.

Perioperative myocardial infarction is one of the more serious problems arising during the performance of CE: previous studies have reported a higher rate than for coronary artery bypass grafting alone. With recent advances in the CE technique, the perioperative myocardial infarction rates have improved and now range from 1.5% to 8% [3, 11–19]. Because of the long arteriotomy, it often takes more time to achieve on-lay patch grafting than to perform CE by the conventional method. Extensive endarterectomy and construction of a long anastomosis are likely to take longer than the 20 minutes usually available between cardioplegia infusions [13]. This problem is more significant when CE is performed on the LAD. To avoid fatal perioperative myocardial infarction, CE was performed with antegrade and retrograde cardioplegic arrest. Care was taken to avoid bleeding from the anterior interventricular vein so as to obtain adequate retrograde cardiomyocyte protection. These techniques extended the limits of safe arrest and the optimal conditions for endarterectomy and multivessel grafting. As a result, a favorable rate of perioperative myocardial infarction could be achieved in the case of on-lay patch grafting.

Our late results (5-year actuarial survival) for patients with on-lay patch reconstruction was better than those for patients who underwent the conventional CE technique. This feature was probably a reflection of the complete removal of all atherosclerotic material and the complete revascularization of the endarterectomized vessels in group O patients.

The size of our angiographic study in CE patients was larger than in previous studies [11, 12, 15, 17, 18, 24, 25]. Because most of the patency quoted in the literature involved selective restudy of certain subgroups of the original cohort, the only way to obtain a true picture of the natural history of endarterectomized grafts was to use both early and late coronary angiography to study, prospectively, a consecutive group of patients. In the literature, the patency rate of CE at 1 year is between 56% and 98% [4–6, 26]. This is dependent on CE technique and on whether or not threadlike arteries are considered to represent graft failure. About 10% of our patent cases were ranked as grade B in the early postoperative stage. Some of these included stenosis of the graft with patency of the native coronary artery in which the proximally extended CE had removed all the stenoses. Of course, incomplete removal of atheromatous plaque might also cause this phenomenon. There is little information on late graft patency, with rates ranging from 40% to 81.5% [11, 17, 19, 24]. Our late patency rate in the on-lay patch group was better than those previously reported and was acceptable when compared with the patency rate of classic ITA bypass grafts on nondiffuse coronary artery lesions [27]. Coronary endarterectomy with the on-lay patch method does not increase the rate of graft failure despite the presence of diffuse coronary lesions.

In our angiographic study, long arteriotomy and ITA on-lay patch grafting is considered to be the preferred method after CE is performed for diffusely diseased coronary artery. Although the number of midterm grade A anastomoses in the on-lay patch group did not differ from the early postoperative stage, the rate of grade A anastomoses in the conventional CE method dropped significantly. These changes may be owing to the development of myofibrointimal proliferation and localized atheroma in the conventional CE method group. In the study on the status of the intima by intravascular ultrasound sonography, although the diameter of endarterectomized vessels was wide in the early postoperative stage, it became narrow as a result of intimal hyperplasia in the late postoperative stage (Figs 4A, 4B). On the other hand, intimal hyperplasia rarely occurred in the on-lay patch group, even in the late postoperative stage. In the intravascular ultrasound sonography study, the intima of the ITA became circumferential, and new intima was constructed in the endarterectomized vessels (Figs 4C, 4D). This coronary reconstruction may be the reason behind the good results in this group. The conventional group included fewer patients receiving endarterectomy to the LAD. However, we do not consider that this accounts for the inferior results in the conventional group because there were no obvious differences of graft patency of ITA or saphenous vein graft between group O and group P. Moreover, there were no obvious differences of graft patency between ITA and saphenous vein graft in the two groups.

View larger version (201K): [in this window] [in a new window]   Fig 4. Evaluation of the status of the intima by intravascular ultrasound sonography at the early and late postoperative stages. In the pull-out method, although the diameters of endarterectomized vessels were wide in the early postoperative stage (A), they became narrow as a result of intimal hyperplasia in the late postoperative stage (B). On the other hand, intimal hyperplasia rarely occurred in group P, even in the late postoperative stage. The intima of the internal thoracic artery became circumferential, and intima was reconstructed in the endarterectomized vessels: (C) early, (D) late.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

1. Williams DO, Holubkov R, Yeh W, et al. Percutaneous coronary intervention in the current era compared with 1985–1986: the National Heart, Lung, and Blood Institute Registries Circulation 2000;102:2945-2951.[Abstract/Free Full Text]
2. Rodriguez A, Rodriguez Alemparte M, Baldi J, et al. Coronary stenting versus coronary bypass surgery in patients with multiple vessel disease and significant proximal LAD stenosis: results from the ERACI II study Heart 2003;89:184-188.[Abstract/Free Full Text]
3. Sundt III TM, Camillo CJ, Mendeloff EN, Barmer HB, Gay Jr WA. Reappraisal of coronary endarterectomy for the treatment of diffuse coronary artery disease Ann Thorac Surg 1999;68:1272-1277.[Abstract/Free Full Text]
4. Brenowitz JB, Kayser KL, Johnson WD. Results of coronary artery endarterectomy and reconstruction J Thorac Cardiovasc Surg 1988;95:1-10.[Abstract]
5. Shapira N, Lumia FJ, Gottdiener JS, Germon P, Lemole GM. Adjunct endarterectomy of the left anterior descending coronary artery Ann Thorac Surg 1988;46:289-296.[Abstract]
6. Ladowski JS, Schatzlein MH, Underhill DJ, Peterson AC. Endarterectomy, vein patch, and mammary bypass of the anterior descending artery Ann Thorac Surg 1991;52:1187-1189.[Abstract]
7. CASS Principal Investigators and Their Associates Coronary Artery Surgery Study (CASS): a randomized trial of coronary artery bypass surgerySurvival data. Circulation 1983;68:939-950.[Abstract/Free Full Text]
8. Baily CP, May A, Lemmon WM. Survival after coronary endarterectomy in man JAMA 1957;164:641-646.
9. Parsonet V, Gilbert L, Gielchinsky I, et al. Endarterectomy of the left anterior descending and maintain coronary arteries: a technique for reconstruction of inoperable arteries Surgery 1976;80:662-673.[Medline]
10. Effler DB, Groves LK, Sone Jr FM, Shirey EK. Endarterectomy in the treatment of coronary artery disease J Thorac Cardiovasc Surg 1964;47:98-108.
11. Tasdemir O, Kiziltepe U, Karagoz HY, 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]
12. Gill IS, Beanlands DS, Boyd WD, Finlay S, Keon WJ. Left anterior descending endarterectomy and internal thoracic artery bypass for diffuse coronary disease Ann Thorac Surg 1998;65:659-662.[Abstract/Free Full Text]
13. Abrahamov D, Tamaris M, Guru V, et al. Clinical results of endarterectomy of the right and left anterior descending coronary arteries J Card Surg 1999;14:16-25.[Medline]
14. Asimakopoulos G, Taylor KM, Ratnatunga CP. Outcome of coronary endarterectomy: a case-control study Ann Thorac Surg 1999;67:989-993.[Abstract/Free Full Text]
15. Barra JA, Bezon E, Mondine P, Resk A, Gilard M, Boshat J. Coronary artery reconstruction for extensive coronary disease: 108 patients and two year follow-up Ann Thorac Surg 2000;70:1541-1545.[Abstract/Free Full Text]
16. Shapira OM, Akopian G, Hussain A, et al. Improved clinical outcomes in patients undergoing coronary artery bypass grafting with coronary endarterectomy Ann Thorac Surg 1999;68:2273-2278.[Abstract/Free Full Text]
17. Ferraris VA, Harrah JD, Moritz DM, Stritz M, Stritz D, Ferraris SP. Long-term angiographic results of coronary endarterectomy Ann Thorac Surg 2000;69:1737-1743.[Abstract/Free Full Text]
18. Santini F, Casali G, Lusini M, et al. 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 2002;21:1020-1025.[Abstract/Free Full Text]
19. Marinelli G, Chiappini B, Eusanio MD, et al. Bypass grafting with coronary endarterectomy: immediate and long-term results J Thorac Cardiovasc Surg 2002;124:553-560.[Abstract/Free Full Text]
20. Fitzgibbon GM, Kafka HP, Leach AJ, Keon WJ, Hooper D, Burton JR. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5,065 grafts related to survival and re-operation in 1,388 patients during 25 years J Am Coll Cardiol 1996;28:616-626.[Abstract]
21. Mills NL. Coronary endarterectomy: surgical techniques for patients with extensive distal atherosclerotic coronary disease Adv Card Surg 1998;10:197-227.[Medline]
22. Walley VM, Byard RW, Keon WJ. A study of the sequential morphologic changes after manual coronary endarterectomy J Thorac Cardiovasc Surg 1991;102:890-894.[Abstract]
23. Lüscher TF, Diederich D, Siebenmann R, et al. Difference between endothelium dependent relaxations in arterial and venous coronary bypass grafts N Engl J Med 1988;319:462-467.[Abstract]
24. Djalilian AR, Shumway SJ. Adjunctive coronary endarterectomy: improved safety in modern cardiac surgery Ann Thorac Surg 1995;60:1749-1754.[Abstract/Free Full Text]
25. Goldstein J, Cooper E, Saltups A, Boxall J. Angiographic assessment of graft patency after coronary endarterectomy J Thorac Cardiovasc Surg 1991;102:539-545.[Abstract]
26. Beretta L, Lemma M, Vanelli D, et al. Coronary "open" endarterectomy and reconstruction: short- and long-term results of revascularization with saphenous vein versus IMA-graft Eur J Cardiothorac Surg 1992;6:382-387.[Abstract]
27. Zeff RH, Kongtahworn C, Iannone LA, et al. Internal mammary artery versus saphenous vein graft to the left anterior descending coronary artery: prospective randomized study with 10-year follow-up Ann Thorac Surg 1988;45:533-536.[Abstract]

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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): Satoru Miyamoto Shuichiro Takanashi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nishi, H. Articles by Shimizu, Y. Search for Related Content PubMed PubMed Citation Articles by Nishi, H. Articles by Shimizu, Y. Related Collections Coronary disease Related Article