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Ann Thorac Surg 2006;81:1179
© 2006 The Society of Thoracic Surgeons

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Correspondence

Reply

Department of Cardiovascular Surgery, Osaka City General Hospital, 2-13-22, Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021 Japan

(Email: nishi24{at}jc4.so-net.ne.jp).

To the Editor:

We appreciate the comments by Drs Singhal and Sundt [1] who provided good points on coronary endarterectomy. Based on early-term and mid-term angiographic patency rates, our results indicated the superiority of the onlay patch technique [2]. This integrity of this technique could not be demonstrated because our analyses were complicated. Therefore we included information from the excellent patency rate (grade A) in our angiographic results. When we compared the patency rate of the internal thoracic artery and saphenous vein graft, no significant differences were found between the onlay patch technique (group O) and the conventional pull-out method (group P). However, when we consider excellent patency rates for individual conduits, the results could have interesting interpretations. Early-term and mid-term internal thoracic artery grade A graft patency rates in group O were 76.1% (32 of 42) and 80.6% (25 of 31), respectively, and in group P the patency rates were 57.7% (15 of 26) and 21.1% (4 of 19), respectively. Furthermore, those of the saphenous vein graft in group O were 85.0% (17 of 20) and 69.2% (9 of 13), respectively, and in group P were 80% (32 of 40) and 55.0% (11 of 20), respectively. For internal thoracic artery and saphenous vein graft, although the mid-term grade A anastomosis rate in group O did not differ from that of the early postoperative stage, the grade A anastomosis rate in group P significantly dropped in the mid-term period, assuming that the grade A patency for individual grafts yields the same results as those of overall graft patency. Therefore our results may confirm the superiority of the onlay patch technique.

Some technical issues need discussion, such as endarterectomy for the right coronary artery and circumflex. Our target vessel for coronary endarterectomy is a diffusely diseased or calcified coronary artery, often with involvement of the distal portion, which was considered to be unamenable to more conventional bypass grafting procedures. The most essential indications are myocardium viability in the territory of the target vessel and adequate size of the distal vessels. Our criterion is that size is more than 1.0 mm. We perform endarterectomy only when these conditions are satisfied. As a circumflex target we always select obtuse marginal artery or posterolateral artery, which arborize from atrioventricular groove due to straight running vessels. It is inevitable to treat the crux (ie, a typically calcified region) when performing right coronary endarterectomy. For this, we always make an incision from the distal right coronary artery to the posterior descending artery for open endarterectomy. If the other major vessel at crux requires endarterectomy, we adapt the eversion technique.

We agree that the retrograde eversion technique is considered unsuitable. Proximal stenosis is essential for coronary endarterectomy because competitive flow from conduit and native coronary artery may affect graft patency and intimal hyperplasia. Avoiding snow-plow phenomenon and obtaining adequate graft flow are crucial to achieve excellent graft patency.

The advantages of the onlay patch grafting are complete removal of diffusely diseased intima, fixation of distal native coronary artery intima, and reconstructing a new adequate coronary wall with conduits. To achieve better patency than that of the eversion technique, these factors are indispensable and may eventually enable obtaining the same results as conventional coronary artery bypass grafting. We would rather believe that the fate of endarterectomy by onlay patch grafting is dictated by the lay of the land; however, it needs to be evaluated by long-term results.

	References

Top References

 

1. Singhal AK, Sundt III TM. Coronary endarterectomythe choice of tactics is dictated by the lay of land (letter). Ann Thorac Surg 2006;81:1178-1179.[Free Full Text]
2. Nishi H, Miyamoto S, Takanashi S, et al. Optimal method of coronary endarterectomy for diffusely diseased coronary arteries Ann Thorac Surg 2005;79:846-852.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Nishi, H. Search for Related Content PubMed Articles by Nishi, H. Related Collections Coronary disease Related Article