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Ann Thorac Surg 2006;81:1178-1179
© 2006 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Temple University, 3401 N Broad St, 3rd Fl, Philadelphia, PA 19140
b Division of Cardiovascular Surgery, Mayo Clinic, 300 First St, SW, Rochester, MN 55905
(Email: singhaak{at}tuhs.temple.edu; sundt.thoralf{at}mayo.edu).
Nishi and colleagues have conducted a remarkable study of endarterectomy in their institution over an 8-year interval obtaining angiographic control studies on 93% to 95% of patients with early and mid-term studies at almost 2 years of follow-up [1]. Their data suggest that open endarterectomy with an onlay patch is a preferable technique to the closed traction or "eversion" endarterectomy. In support of this, they site remarkable late patency of the open endarterectomy group, particularly when an internal thoracic artery graft was used. They recommend long arteriotomy and internal thoracic artery onlay patch grafting as "the preferred method" for coronary endarterectomy.
We have had some interest in coronary endarterectomy during the years as well, and we also strongly prefer the open endarterectomy technique as applied to the left anterior descending. We prefer use of the spatulated internal thoracic artery as a long onlay patch for reconstruction in this circumstance as do the authors. Endarterectomy of the right coronary artery and circumflex, however, is a different story. The right coronary is typically less amenable to such an approach, particularly at the crux. Which branch does one follow, the posterior descending or the continuation of the right? In our experience, eversion endarterectomy is preferable for the right coronary for this reason. If a plaque fractures in one of these two major branches, the arteriotomy can be extended down that vessel. Similarly, the circumflex system tends to arborize more extensively than the left anterior descending artery, making extended open endarterectomy more complex. Again, which branch does one follow?
We are concerned that the analysis provided by the authors is, in fact, more of a comparison of endarterectomy of the left anterior descending artery with internal thoracic artery reconstruction to endarterectomy of other vessels with a saphenous reconstruction than it is a true comparison of endarterectomy techniques. In the eversion group, only 32% of endarterectomies were to the left anterior descending artery, whereas almost 50% were of the right. In the open group, the opposite held true with approximately 65% of endarterectomies being of the left anterior descending artery and 22% of the right. The impact of coronary system on graft patency is already well established with regard to internal thoracic artery grafts, radial artery grafts, and saphenous vein grafts, and based on this study these results can be broadened to include coronary endarterectomy. Furthermore, in the open group 80% (54 of 68) received an internal thoracic artery conduit, whereas the internal thoracic artery was used only 44% (26 of 59) of the time in the eversion group. Beretta and colleagues [2] have previously demonstrated patency rates of 82% for internal thoracic artery versus 67% for saphenous vein grafts in coronary endarterectomy at 36 months based on follow-up angiograms. Furthermore, examining the authors' own data presented in Table 4 of their paper, when conduit choice is fixed by comparing patency of only internal thoracic conduits or saphenous veins to targets treated by open or eversion technique, the differences are not significant. Is it appropriate to compare cumulative patencies of these quite different systems with such different distribution of techniques?
We would also highlight our agreement with the invited commentators Drs TasDemir and Kucuker in regard to retrograde eversion endarterectomy. It is a technique mentioned only to be condemned. An attempt to endarterectomize the proximal vessel using eversion technique assures one of sheering off any and all branches of that vessel. The consequence is the snowplow phenomenon illustrated graphically by Dr Effler in his original landmark article on the subject [3].
We believe that the choice between eversion endarterectomy and open endarterectomy is dictated by coronary anatomy, agreeing that open endarterectomy, when practicable, is preferable. The author's data should discourage eversion endarterectomy of the left anterior descending artery. However, attempting an open endarterectomy of a 1-mm posterior descending vessel is unlikely to be a gratifying experience. Unfortunately, as much as we try to be masters of our fate, often the tactics we may most effectively apply are dictated to us by the lay of the land.
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  H. Nishi Reply. Ann. Thorac. Surg., March 1, 2006; 81(3): 1179 - 1179. [Full Text] [PDF]
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