Coronary Endarterectomy: A Single Surgeon Experience of 392 Consecutive Patients over Eighteen Years
West-German Hear and Vascular Center, Essen, Germany.
OBJECTIVE: Surgical treatment strategies for patients presenting with severe diffuse coronary artery disease are debated controversial. Coronary endarterectomy (CEA) is a time honored established treatment option to treat such pathologies, but many surgeons avoid it due to reported ambivalent results. Therefore, we aimed to review our experience with CEA in CABG surgery. METHODS:
Prospectively sampled data, retrospective single surgeon observational study, with 392 consecutive patients included between 03/1999 and 12/2016 undergoing CABG and CEA for occluded/sub-occluded vessels within viable myocardium. Major adverse cardiac and cerebrovascular events (MACCE) and 30-day mortality, as well as overall survival were estimated. Follow up was complete for 91% of the patients.
In 392 patients undergoing CABG (age: 64.5±8.8years, male: 85.7%), a total of 478 CEAs were performed. Most patients 357(91%) had three-vessel disease, 27(6.9%) patients had previous cardiac surgery and 107(27.3%) patients were referred for urgent/emergent surgery. Concomitant procedures were required in 101/392 (25.8%). Patients had a mean of 4.2±1.1 grafts. CEA target was the LAD territory in 215/478 (44.9%), LCX territory in 76/478 (15.9%), and RCA territory in 187/478 (39.1%). Transit time flow measurement through the CEA graft resulted in 72.8±52.3 ml/min mean. Patients received either single (200, 51%) or dual antiplatelet therapy (192, 49%) to prevent early graft failure. MACCE consisted of stroke in 10 (2.6%), myocardial infarction in 9 (2.3%) and 30-day mortality for isolated CABG in 11/291(3.7%) patients. Follow-up imaging with angiography/CT-A was available in 63 patients (in 25 due to recurrent angina, in 38 patients for research reasons) with 72 grafts after CEA. Graft occlusion was documented in 13/72 (all saphenous vein grafts) at a mean follow-up time of 4.9±4.3 years. All LITA grafts to the LAD were patent. Long-term survival is demonstrated on Fig.1.
CONCLUSIONS: Patients with severe diffuse coronary artery disease are considered high-risk candidates for surgical revascularization. Although CEA is a complex procedure, it still offers a valid surgical option to achieve complete revascularization with acceptable short and long-term results. Concomitant dual antiplatelet therapy seems to improve patency rates over time.
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