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Adjunct endarterectomy of the left anterior descending coronary artery
N Shapira1, F J Lumia, J S Gottdiener
1Department of Surgery, Veterans Administration Medical Center, Washington, DC.
Insights
Extensive endarterectomy combined with bypass grafting offers complete revascularization for complex left anterior descending artery disease. This approach yields excellent long-term functional outcomes with low morbidity and mortality.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Vascular Biology
Background:
- Diffuse left anterior descending (LAD) coronary artery disease poses challenges for conventional bypass grafting.
- Complete revascularization is crucial for optimal patient outcomes in coronary artery disease.
Purpose of the Study:
- To evaluate the efficacy and safety of extensive endarterectomy combined with bypass grafting for LAD revascularization.
- To assess the long-term functional results and morbidity associated with this combined surgical approach.
Main Methods:
- A retrospective analysis of 37 patients undergoing LAD endarterectomy and bypass grafting over a three-year period.
- Utilized left internal mammary artery (LIMA) in 22 patients for bypass.
- Assessed outcomes through 100% follow-up (mean 41.4 months), functional class, and radionuclide angiographic stress testing.
Main Results:
- One operative death (2.7%) and one perioperative myocardial infarction.
- All patients achieved New York Heart Association Functional Class I or II at follow-up.
- 83% of patients demonstrated excellent exercise tolerance (5-7 METs), with preserved left ventricular functional reserve (ejection fraction increased from 48% to 59% with exercise).
Conclusions:
- Adjunct endarterectomy with bypass grafting provides complete revascularization for diffusely diseased LAD arteries when conventional methods fail.
- This technique is associated with acceptable operative risk and excellent long-term functional recovery.
- Both LIMA and vein grafts are effective for bypassing the endarterectomized LAD artery.
Abstract:
During a three-year period, complete revascularization of diffusely diseased left anterior descending (LAD) coronary arteries was accomplished by extensive endarterectomy in conjunction with bypass grafting in 37 patients in whom conventional bypass was not feasible. This group constituted 7.0% of all patients undergoing nonemergency coronary revascularization during this period. The left internal mammary artery was used to bypass the endarterectomized LAD artery in 22 patients. There was 1 (2.7%) operative death and 1 perioperative myocardial infarction. At follow-up, which was 100% with a mean of 41.4 months, all endarterectomy patients were in New York Heart Association Functional Class I or II. Twenty-four endarterectomy patients underwent first-pass radionuclide angiographic stress testing 20 months after operation. Twenty patients (83%) had excellent postoperative exercise tolerance, achieving 5 to 7 mets on treadmill testing. Left ventricular functional reserve was preserved, as evidenced by an increase of global ejection fraction from 48 +/- 15% at rest to 59 +/- 18% (p less than 0.005) with exercise. A similar increase was measured in the proximal and distal anterior wall segmental ejection fractions. No difference in response to exercise was found between the internal mammary artery and the vein graft groups. Thus, complete revascularization of the diffusely diseased LAD artery can be accomplished by adjunct endarterectomy without added morbidity or mortality and with excellent functional results.