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Ann Thorac Surg 2005;79:852-853
© 2005 The Society of Thoracic Surgeons
Cardiovascular Surgery Clinic, Cankaya Hospital, Bulten Sokak, No: 44, Kavaklidere Cankaya/Ankara, Turkey 06700
Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey 06100
(E-mail: otasdemir{at}superonline.com).
Several studies indicate that patients with diffuse coronary artery disease in whom standard coronary bypass techniques cannot be performed constitute up to 25% of all patients with coronary artery disease. In the modern era of invasive interventional cardiology, the referral number of patients with diffuse coronary artery disease will continue to increase. Therefore, the present study by Nishi and colleagues offers some major contributions to coronary surgery, by providing valuable early and late postoperative angiograms of patients with coronary endarterectomy. The authors should be congratulated for their high rate of postoperative angiographies which reached more than 80%.
The most important finding of this study is that with open endarterectomy and on-lay patch grafting, the rate of grade A anastomosis (free of stenosis or occlusion) at mid-term angiographic studies was not different from that found early. In contrast, the rate of grade A anastomosis in conventional pull out endarterectomy group significantly dropped from early to mid-term. This is a remarkable finding and should be kept in mind while operating with diffusely diseased coronary arteries.
While describing the conventional pull out method, the authors mention application of closed traction for distal and proximal branches. According to our experience, proximal dissection plane should end at the end of the arteriotomy and plaque should be transected at this point. Blind proximal endarterectomy, particularly on the left anterior descending artery, may disrupt flow into major proximal branches, including the circumflex artery, a ramus artery or septal arteries.
One other technical issue, although not advocated but performed by the authors needs some discussion. Some of the conventional endarterectomy patients in this study had more than one arteriotomy. Bypass grafts were anastomosed to the most proximal arteriotomy and the rest was closed with a patch. This method seems to be time consuming and technically difficult to perform and has inferior angiographic results when compared with other conventional or open endarterectomy patients. When a distal arteriotomy becomes necessary, one should avoid this method altogether and proceed with open endarterectomy instead.
The authors are to be congratulated for their late high ITA patency rates that are comparable with the patency rates of classic ITA bypass grafts on nondiffuse coronary artery lesions. This is achieved with long open arteriotomy and ITA on-lay patch grafting. In light of the present and similar studies, the conventional pull out method for diffusely diseased left sided arteries, particularly for the LAD, should be avoided and open endarterectomy with ITA on-lay patch grafting should be the preferred endarterectomy method whenever suitable.
Related Article
Ann. Thorac. Surg. 2005 79: 846-852.
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