Ann Thorac Surg 1999;68:2278
© 1999 The Society of Thoracic Surgeons
Invited Commentaries
Wilbert J. Keon, MDa
a University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON K1Y 4W7, Canada
e-mail: wjkeon{at}ottawaheart.ca
Invited commentary
This case-control summary of clinical results of patients undergoing coronary endarterectomy at Boston University has particular relevance to the evolving practice of coronary surgery worldwide. Whereas conservative application of this technique was held in the earlier years of practice, by necessity, the frequency in which endarterectomy has to be resorted to has significantly increased. Patients with eccentric coronary plaques are treated with angioplasty and stents deferring surgery until later in the evolution of the disease. Diffuse disease is now commonplace, and means to deal with this problem are desperately needed. The Boston group has illustrated that the perioperative results with this population are virtually identical to the excellent results they have already achieved with their standard coronary population. The perioperative infarction rate, already minimized with the use of such techniques as heparin-coated circuits and low heparin, is quite acceptable and illustrates that the once-held fear of progressive myocardial damage with this technique is unfounded. My practice is also to use the traction technique for the majority of endarterectomy cases. However, we also use multiple incisions where further exploration of the coronary bed is necessary. An arterial or venous graft is inserted at the most proximal incision and the distal incisions are closed over steel probes of appropriate size.
In diffuse coronary disease, endarterectomy is the only surgical option and can produce good clinical results in otherwise inoperable patients. Experimental approaches such as transsternal or percutaneous laser myocardial revascularization may in time present an alternative. In our practice, experience with endarterectomy continues to grow, with short and long-term results comparable to routine bypass revascularization.
