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Angioscopic evaluation of intravascular morphology after coronary endarterectomy
B E Keogh1, B P Bidstrup, K M Taylor
1St George's Hospital, London, England.
Insights
Coronary endarterectomy can cause intraluminal flaps, increasing risks. Angioscopy after the procedure revealed these flaps in all studied arteries, but small side branches remained unaffected.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Medical Imaging
Background:
- Coronary endarterectomy for diffuse coronary disease is linked to higher rates of perioperative myocardial infarction and graft occlusion.
- These complications are partly attributed to intraluminal flaps and thrombogenic material within the coronary arteries post-procedure.
Purpose of the Study:
- To investigate the nature and incidence of intraluminal flaps after coronary endarterectomy.
- To assess the utility of angioscopy for immediate post-intervention evaluation of coronary morphology.
Main Methods:
- Fifteen patients undergoing coronary endarterectomy for multivessel disease were studied.
- Post-endarterectomy angioscopy was performed using a 1.8-mm scope during graft perfusion to visualize the main vessel and side branches.
- Intravascular morphology, including intraluminal flaps and side branch integrity, was assessed.
Main Results:
- Angioscopy revealed wispish intraluminal fronds and medial bruising in 100% of the endarterectomized arteries.
- Major intraluminal flaps were observed at 8 of 30 major endpoints and 6 of 21 visualized smooth tapered endpoints.
- Flaps were present at only one of fifteen visualized minor side branch origins, indicating minimal compromise to smaller vessels.
Conclusions:
- Coronary endarterectomy is associated with intraluminal findings, including flaps, in all treated arteries.
- Angioscopy is an effective tool for immediate post-intervention assessment of intravascular morphology, with minimal impact on ischemic time.
- The study suggests that small side branches are generally not compromised by the endarterectomy procedure.
Abstract:
Coronary endarterectomy in diffuse coronary disease is attended by an increased incidence of perioperative myocardial infarction and vein graft occlusion, which have been partially attributed to the presence of occlusive or thrombogenic intraluminal flaps in the main vessel or its smaller branches. To define the nature and incidence of these features we studied 15 endarterectomized right coronary arteries in 15 patients (12 men, 3 women; age, 55 +/- 7 years [mean +/- standard deviation]) undergoing a coronary operation for multivessel disease. After endarterectomy and distal graft anastomosis, angioscopy was performed using a 1.8-mm Olympus angioscope during graft perfusion with crystalloid solution. The endarterectomy cores were 66 +/- 30 mm in length with 11 major bifurcations and two trifurcations providing 30 major endpoints. At 22 of 30 major endpoints the distal end of the core was smooth and tapered. There were 17 minor side-branch endpoints. Angioscopy revealed the presence of wispish intraluminal fronds and medial bruising in all (100%) arteries. Twenty-nine of the 30 intraluminal endpoints could be visualized. Major intraluminal flaps were seen at the eight nontapered endpoints and six of the 21 smooth tapered endpoints that were visualized. Fifteen minor side branches could be identified angioscopically: a flap was seen at only one side-branch origin. The average examination time was 3.2 +/- 1.1 minutes (7.7% +/- 2.7% of cross-clamp time), and examination required 200 to 250 mL of perfusate. This technique enables immediate and accurate postinterventional assessment of intravascular morphology with minimal prolongation of ischemic time and has shown that small side branches are not compromised by endarterectomy.(ABSTRACT TRUNCATED AT 250 WORDS)