Ann Thorac Surg 2006;81:1691-1696
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Early and Late Outcome After Off-Pump Coronary Artery Bypass Graft Surgery With Coronary Endarterectomy: A Single-Center 10-Year Experience
Hunaid A. Vohra, MD,
Raj Kanwar, MRCS,
Tanveer Khan, FRCS,
Wade R. Dimitri, FRCS
*
Department of Cardiothoracic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Walsgrave Hospital, Coventry, United Kingdom
Accepted for publication December 7, 2005.
* Address correspondence to Dr Dimitri, Department of Cardiothoracic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Walsgrave Hospital, Coventry, United Kingdom (Email: wade.dimitri{at}uhcw.nhs.uk).
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Abstract
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BACKGROUND: We aimed to review the early and late results of off-pump coronary artery bypass graft surgery (OPCABG) with coronary endarterectomy in patients undergoing surgical revascularization at our institution.
METHODS: Between 1995 and 2004, of 680 OPCABG patients in a single surgeon's practice (W.R.D.), 70 patients (10.29%) who underwent concomitant coronary endarterectomy were studied. The mean age was 63.6 ± 9.29 years. Thirty-three patients (55%) were Canadian Cardiovascular Society class III or IV, and 24 patients (40%) were New York Heart Association class III or IV. Eighteen patients (35%) had impaired left ventricular function. The mean EuroSCORE of these patients was 5.9 ± 1.8.
RESULTS: Fifty-seven patients (81%) underwent right coronary artery endarterectomy, and 12 patients (17%) underwent left anterior descending artery endarterectomy (8 left interior mammary arteries used as conduits). Four patients (5.7%) had two vessels endarterectomized. The mean number of grafts were 2.0 ± 0.4. The 30-day mortality rate was 2.85% (n = 2). Three patients (4.3%) suffered from postoperative myocardial infarction, and 3 patients (4.3%) required postoperative intra-aortic balloon pump counterpulsation. Mean intensive therapy unit stay was 17.6 ± 8.1 hours. Patients were extubated after a mean of 10.38 ± 4.9 hours. The mean length of hospital stay was 6.1 ± 2.0 days. Fourteen patients (20%) had postoperative atrial fibrillation, and only 1 patient (1.42%) had a transient stroke with complete recovery. There were no conversions to cardiopulmonary bypass. A mean of 0.86 ± 0.17 units of blood were transfused postoperatively. There was one reopening for bleeding, and 1 patient had renal failure requiring hemofiltration. The median follow-up was 4.91 years, 90% of patients were angina free, and the actuarial survival at 10 years was 78.04% ± 7.6%.
CONCLUSIONS: Off-pump coronary artery bypass graft survery with coronary endarterectomy is feasible and achieves surgical revascularization in patients with diffuse coronary artery disease.
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Introduction
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In recent years, cardiac surgeons are being referred patients with diffuse coronary artery disease for consideration for coronary artery bypass grafting (CABG) with increasing frequency. Despite the introduction of coronary endarterectomy (CE) 40 years ago [1, 2] as a method of treatment of diffuse coronary artery disease, its application remains controversial [3–6] as it carries a higher perioperative risk and poorer long-term survival [7–9]. It is a technically challenging procedure even when cardiopulmonary bypass (CPB) is used, and as a result, some surgeons may avoid undertaking it because of inadequate experience, leading to incomplete revascularization. More recently, although several authors have reported [10–12] better short-term outcome and improved long-term survival, it is still performed in a small proportion of CABG patients, in contrast to earlier decades when it was performed more frequently [7]. Furthermore, to avoid the institution of CPB with its attendant risks of inflammation and global ischemia [13, 14], off-pump coronary artery surgery (OPCABG), which is again very challenging, is considered by some present day centers as the technique of choice for the surgical management of coronary artery disease, especially in high-risk patients[15, 16]. This study was undertaken to assess the feasibility of OPCABG and to review our overall experience with patients undergoing OPCABG with concomitant CE.
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Patients and Methods
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Between January 1995 and May 2004, of 680 OPCABG patients in a single surgeon's practice (W.R.D.), 70 (10.29%) underwent concomitant CE. Any patient suitable for OPCABG (which in our practice includes those with poor left ventricular and left main stem disease) was considered for off-pump endarterectomy. In all cases, once the decision was made to perform an endarterectomy, this was pursued off-pump as long as endarterectomy was feasible and could be achieved with safety. The preoperative characteristics are listed in Table 1. Clinical data were prospectively collected and entered into a database. Also, the clinical notes of these patients were reviewed. When the information provided by the clinical notes was not adequate, the patient's general practitioner was contacted by telephone. The study was approved in April 2004 by the Clinical Study Review Department at our institution, and patient consent was waived. Postoperative myocardial infarction was defined as persistent electrocardiographic changes such as new Q waves, loss of R-wave progression, new intraventricular conduction defects, or new echocardiographic evidence of wall motion abnormality. Electrocardiograms were performed in all patients on day 1 and day 4 postoperatively and more frequently if required. The median follow-up was 4.91 years (range, 0.9 to 9.4). Eleven patients were followed up for more than 8 years. Four patients were in their 10th year of follow-up.
Surgical Procedure
Standard intraoperative monitoring techniques were used. A CPB circuit was on standby for all cases. All procedures were performed through a median sternotomy. After the conduits (internal thoracic arteries, the radial artery, and the saphenous vein) were harvested, heparin was administered to maintain an activated clotting time greater than 400 s. A cell-saving device was used for blood recovery from 2002 onward. Metoprolol was administered intravenously to maintain a heart rate of 50 to 60 beats per minute. Esmolol was scarcely used. As experience progressed and techniques and technologies evolved, a variety of methods and stabilizing devices were used to immobilize the coronary arteries. We used the suction-type (Octopus 3; Medtronic, Minneapolis, MN) and the compression type (Ultima OPCABG system; CTS-Guidant, Indianapolis, IN) mechanical stabilizers to immobilize the target coronary artery. A heart positioner (Guidant AXIUS Xpose Access Device 3, and the improved Medtronic Starfish 2) was used in the latter part of the series to expose the posterior and inferior surfaces of the heart.
Although the indication that a coronary endarterectomy may be required can be obtained from the coronary angiogram, the final decision to endarterectomize a vessel is made intraoperatively and is based on technical considerations. Complete occlusion on angiogram was not considered a definite indication for endarterectomy. Coronary endarterectomy was considered when no adequate segment of a vessel, supplying viable muscle with reversible ischemia, was suitable for grafting. Apparently patent and therefore graftable segment on angiogram was on occasion found unsuitable due to severe narrowing or heavy calcification precluding effective anastomosis. Endarterectomy of the diseased vessel was only performed when the artery was completely or nearly occluded with heavily calcified plaques and long stenoses that extending distally.
The arteriotomy was commonly approximately 1.5 cm long, but was extended for another 0.5 cm in few cases. That was more likely to occur in the left anterior descending artery (LAD) than right coronary artery (RCA). Hence, open CE and vein patch were not used in any cases, and the incision in the conduit was extended to match the arteriotomy. A fine dissector was used to develop a distal plane between the adventitia and the atheromatous core. The atheroma is then held with a pair of large blunt forceps in the middle, and gentle sustained traction [17, 18] is applied distally cranially. Only 1 to 2 cm of the proximal core is dissected, and the atheroma divided at this level because of the risk of competitive flow between the graft and the native vessel that may compromise flow through the graft. Thus, complete proximal endarterectomy should be avoided. It is often helpful to tease the adventitia distally over tenacious segments using peanut swab dissection or by lifting and picking the external layers, thus enhancing layer separation.
We noted that lesser traction is required with off-pump CE, as countertraction by the beating heart assists in distal dissection and removal of the atheroma. To ensure complete removal of the distal atheroma, the core is carefully inspected to visualize the smooth distal tapering end (Fig 1). Moreover, back flow of blood from the distal vessel during the dissection and after complete extraction of the atheroma is a reassuring sign of satisfactory progress that is unique to OPCABG endarterectomy. A probe was not introduced distally owing to the fear of raising a flap at the site of termination of endarterectomy and risk of dissection.
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Fig 1. Complete removal of the atheromatous core from the right coronary artery (RCA): starting on the left of the figure is the main RCA atheroma, which divides into the posterior descending artery (PDA), going downward in the figure, before continuing in to the atrioventricular groove, going to the right. Note the smooth distal tapering end of the RCA and the PDA atheroma. Also note the atheroma in septal branches given off by the PDA.
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If the surgeon was unhappy with the completeness of endarterectomy as judged by the inspection of the distal core and inadequate backbleeding, the distal vessel was carefully palpated and a second incision was made distally, allowing the atheromatous core to be completely removed. In this way, atheromas measuring approximately 10 cm can be removed from the diseased vessel. In the earlier part of the study, proximal and distal snares and vascular occluders were used to control blood in the surgical field resulting from forward flow and backbleeding. Intracoronary shunts were used since their introduction in 2002, whenever possible (short arteriotomies and smaller residual vessel diameter).
The distal anastomosis to the endarterectomized vessel was constructed end to side using 7-0 polypropylene sutures using standard techniques. In some cases with a long arteriotomy, a vein patch was used to reconstruct the anastomosis. Aspirin, 75 mg, was commenced postoperatively once bleeding had settled, and all patients since 2003 have been also prescribed clopidogrel, 75 mg.
Statistics
Preoperative and postoperative data are expressed as means ± SD. The Kaplan-Meier method was used to analyze actuarial survival and freedom from angina. Statistical analysis was performed using SPSS software (release 12.0.1 for Windows; SPSS, Chicago, Illinois).
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Results
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Fifty-seven patients (81%) underwent RCA endarterectomy (conduit used: 4 radial arteries, 1 small saphenous vein, 52 great saphenous veins), 12 patients (17%) underwent LAD endarterectomy (conduit used; 8 left internal mammary arteries, 4 great saphenous veins), and 1 patient underwent obtuse marginal endarterectomy (conduit used: 1 great saphenous vein). Four patients (5.7%) had two vessels endarterectomized whereas the rest had single-vessel endarterectomy. The mean number of grafts was 2.01 ± 0.44. No patient required ventilation for more than 24 hours, and there were no conversions to cardiopulmonary bypass. A mean of 0.86 ± 0.17 units of blood was transfused postoperatively, and 70% of the patients required 1 unit or less. The 30-day mortality rate was 2.8%, and there were 9 late deaths. The follow-up was 95.7% complete (67 patients); 90% of patients were angina free at median follow-up of 4.6 years, and the actuarial survival at 10 years was 78.04% ± 7.6% (Fig 2). The rest of the postoperative characteristics are listed in Table 2.
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Fig 2. Actuarial survival curve (for 67 patients) showing freedom from death at 5 and 9.4 years of follow-up. The x axis shows time in years and the y axis shows the fraction of patients alive. (Cum = cumulative.)
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In our conventional CABG practice, 10.8% patients (n = 125 of 1,153) underwent CE. Right coronary artery endarterectomy was performed in 65%, LAD endarterectomy in 28%, and RCA plus LAD endarterectomy in 6.4% patients.
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Comment
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There are few series reporting adjunctive CE during OPCABG procedures. Tamim and associates [19] reported two cases with severe aortic calcification whereas Eryilmaz and associates [20] reported 11 cases in patients with poor left ventricular function. Careaga and colleagues [21] and Naseri and associates [22] reported 8 and 44 cases, respectively. Off-pump CABG surgery for multivessel myocardial revascularization in high-risk patients has been shown to reduce the incidence of perioperative morbidity [23–25] and the period of hospitalization [26]. The very low incidence of readmission to the intensive care unit (nurse:patient ratio 1:1, cardiac monitoring, immediate access to advance cardiac life support, arterial line and pulmonary artery catheter placement, temporary pacemaker placement, mechanical ventilation, intra-aortic balloon placement, and vasoactive continuous intravenous infusions), return to theater for bleeding or tamponade, infection, and stroke in these high-risk patients in our OPCABG series with concomitant CE compares favorably with the published OPCABG literature [23, 24, 27, 28]. Naseri and associates [22] also showed that the intubation time, intensive care unit stay, and the length of hospital stay after OPCABG with CE was less than conventional coronary endarterectomy (CCE). Furthermore, although the duration of ventilation was similar in our study and that of Eryilmaz and associates [20], the duration of hospitalization was higher in the latter series (17.4 versus 6.1 days). One patient in our study had transient stroke with complete recovery, which concurs in the study of Naseri and associates [22], who reported no neurologic deficit.
Incomplete revascularization has been shown to be one of the most important factors that affects perioperative morbidity, ventricular function, reoperation rate, and early and late mortality [16, 29]. Proper revascularization of the LAD is considered as a vital determinant of the patient's prognosis [16, 29). However, LAD endarterectomy is considered to be higher risk than other territories [7], and therefore may be avoided by some surgeons. Although, in our series of OPCABG with CE, the commonest site of CE was the RCA (81%), LAD endarterectomy was required to be performed in 17% of these patients. Interestingly, LAD endarterectomy was performed in only 1.8% of the whole OPCABG series. If the disease was subclinical, that was not grafted; and if there was extensive disease and the vessel was small, that precluded revacularization. This rule applies to all territories. Significant disease was not ignored in any vessels. Indeed, one can imagine that the endarterectomized vessel was the predominant source of the patient's symptoms.
Previously, the internal mammary artery (IMA) has been used cautiously as a conduit to an endarterectomized vessel because of concerns regarding mismatch of luminal diameter [10]. With CCE, however, several authors have now reported satisfactory early and late clinical outcomes and luminal patency of IMA to an endarterectomized vessel compared with great saphenous vein [11, 30, 31]. It has been argued [32] that the use of the IMA for reconstruction of the LAD leads to reduced perioperative myocardial infarction, improved early patency, and improved 5-year survival. We have therefore utilized the left IMA to LAD in 66% of our cases.
The endarterectomy technique of choice is still a matter of controversy [10, 11, 17, 18, 30, 31, 33]. We generally use the "traction technique" to perform endarterectomy. This technique is simpler, performed through a small incision, and easier to reconstruct [17, 18]. The potential risks include incomplete removal of the plaque and the "snow-plow effect," namely, shearing-off of the plaque in the side branches. With the "open technique." the vision is better, and that may lead to more complete removal of the atheroma from the coronary vessel and its side branches [17, 18]. The procedure is lengthy, however, and reconstruction of the anastomosis frequently requires a patch repair. The traction technique was therefore preferred in most cases, with careful inspection of the atheroma after removal. Extending the arteriotomy was only performed if it was thought that there was a residual plaque in the distal vessel, and that was limited to retrieving the distal core. Myocardial contraction in the region of the LAD artery is more vigorous than the RCA territory. That helps in the extraction of the distal atheromatous core by simple traction and makes it easier as compared with removal in the RCA. The myocardium in the region of the RCA is thinner, and gentle stroking with peanut swab dissection externally on the epicardium in the direction opposite to traction and the use of a fine dissector (which may also be used in LAD) internal to the adventitia aids in removal of the atheroma.
Myocardial infarction (MI) secondary to acute graft closure is a major complication after CCE with a reported incidence of 1.5% to19% [7, 8, 10, 11, 34–36] and is higher when CE is not performed. The incidence of MI in our patients who underwent OPCABG without CE is 0.8% (5 of 610); 4.3% (3 of 70) of our OPCABG with CE patients had MI postoperatively. However, proper biochemical analyses for infarct would probably show a higher incidence, especially around day 3 or 4 [37]. Naseri and associates [22] reported a higher postoperative MI rate of 6.8% after OPCABG with CE in totally occluded or greater than 50% stenosis. Djalilian and colleagues [11] reported an increased MI rate in endarterectomized vessels performed under cardiopulmonary bypass that were not completely occluded [11]. The rate of recurrent angina of 10% that we observed is comparable to that reported by other authors after CCE. Gill and associates [31] observed recurrent angina in 15% of their patients at a mean follow-up of 36 ± 16 months, whereas Djalilian and associates [11] reported the same in only 9% of their patients at 46 ± 19 months. Christakis and coworkers [38], however, reported a 65% freedom from angina at 5 years. This difference in recurrence of symptoms may be due to the particularly severe nature of the coronary disease present among the local population or to suboptimal revascularization achieved. One of the limitations of our study is the lack of follow-up angiographic data. However, it is encouraging to note that at the time of follow-up, 90% of patients were angina free, which is a considerable improvement when compared with preoperative status.
To minimize the risk of acute graft or native-vessel thrombosis after CCE, particularly for left-sided endarterectomies [11, 18, 33, 38], routine intravenous infusion of heparin, dipyridamole, or dextran is recommended by some authors in the immediate postoperative period, followed by warfarin for several months. However, our practice is that, once the bleeding settles, aspirin is administered [17, 18], and clopidogrel is given for a period of 6 weeks.
The reported incidence of early mortality after CCE is between 2% and 15% [7–11, 34–36, 39–41] and is higher than that of patients undergoing CABG without CE in the same institutions. In the context of OPCABG with CE, Careaga and associates [21] and Erylimaz and colleagues [20] reported a 30-day mortality of 0% in their small series. Naseri and associates [22], who compared CCE and OPCABG with CE, reported a mortality of 2.2% in a series of 44 patients with the latter technique. In our larger series of 70 high-risk patients, the early mortality of 2.8% in the endarterectomized group is higher when compared with OPCABG without endarterectomy in 610 patients for whom the mortality rate was 1.3% (n = 8). Early death is reported to be higher after LAD endarterectomy [7] and in patients undergoing endarterectomy of more than 1 coronary artery [10]. Although the number of multiple endarterectomies was low (5.7%), both our early deaths followed endarterectomy that did not involve LAD. In our experience, enadarterectomy of the circumflex territory is generally unnecessary when there is diffuse disease and extensive calcification due to the small caliber of the vessels. That applies to both conventional coronary endarterectomy and that performed off pump.
Actuarial survival rates of 96.7% at 1 year [35] and 71% to 92% at 5 years after CCE [7, 10, 11, 35, 36, 38, 39] have been reported. After OPCABG with CE, Erylimaz and colleagues [20] reported no deaths at 1-year follow-up in their small series. Our 91.5% 1-year survival, 87.9% 5-year survival, and 78% 10-year survival rates are impressive as compared with those after CCE. In the context of OPCABG with CE, however, we could not find long-term follow-up in a large series of patients in the literature.
Owing to the increasing number of patients with diffuse coronary artery disease being referred for OPCABG, there is a need to reassess the early and medium-term postoperative outcomes in patients undergoing primary OPCABG with CE in modern cardiac surgery. Despite the higher risk profile, hospital mortality and major complications in our study are comparable to those for CCE. In the largest series of OPCABG with CE so far, we have shown that the effect of OPCABG with CE appears to be durable, and long-term clinical outcomes are encouraging. Hence, diffuse disease requiring endarterectomy should not be considered a contraindication to OPCABG. Surgical skills and the suitability criteria of the patients are very important in this regard.
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Acknowledgments
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We are grateful to David P. Taggart, Professor of cardiovascular surgery, University of Oxford, for his useful comments.
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Abstract
Introduction
