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Coronary endarterectomy. An adjunct to coronary artery bypass grafting
W J Keon1, R G Masters, A Koshal
1Department of Surgery, University of Ottawa, Ontario, Canada.
Insights
Results for endarterectomy with coronary artery bypass grafting vary widely due to patient selection and surgical expertise. Careful patient selection is crucial for potential benefits, but more data is needed.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Reported outcomes for endarterectomy combined with coronary artery bypass grafting (CABG) show significant variability.
- Operative mortality, perioperative infarction, and graft patency rates differ substantially across studies.
Purpose of the Study:
- To analyze the reasons for the wide discrepancy in reported clinical outcomes of endarterectomy in conjunction with CABG.
- To evaluate the role and risks of endarterectomy for patients with diffuse coronary artery disease.
Main Methods:
- Review of existing literature on endarterectomy combined with CABG.
- Analysis of factors contributing to outcome variability, including patient selection, surgical experience, and technique.
Main Results:
- Wide ranges reported: operative mortality (0-10%), perioperative infarction (5-30%), and patency rates (38-100%).
- Variability attributed to non-standardized patient selection, evolving surgical techniques over time, and the technical learning curve of endarterectomy.
- Carefully selected patients may benefit, but risks of morbidity and mortality must be considered.
Conclusions:
- Endarterectomy should be reserved for cases where conventional bypass grafting is not feasible.
- Lack of prospective randomized controlled trials limits statistical support; ethical concerns exist for such studies.
- Clinical decisions require a case-by-case approach, emphasizing careful patient follow-up and data scrutiny.
Abstract:
There is a wide variation in the reported results of endarterectomy in conjunction with coronary artery bypass grafting. Operative mortality ranges from 0 to 10 per cent, perioperative infarction ranges from 5 to 30 per cent, and patency rates range from 38 to 100 per cent, with 74 to 95 per cent being asymptomatic or improved. This wide discrepancy in clinical outcome occurs for a number of reasons. First, there is nonhomogeneity of patient populations resulting from a lack of standardized patient selection criteria. Second, the operative experience of most published reports spans a decade throughout which major advances in cardiac surgery have occurred. Finally, endarterectomy is a technically challenging procedure with its own learning curve. Differences in technique and expertise almost certainly contribute to the variability of results. Patients with diffuse coronary artery disease pose a challenge to the cardiac surgeon. Endarterectomy entails the risks of increased morbidity and mortality and therefore should be done only if conventional bypass grafting is precluded. However, the risks of these complications must always be weighed against the possible benefits. At the present time carefully selected patients can benefit from this procedure. Unfortunately, until such time as controlled randomized studies are carried out on a prospective basis, statistical support for this procedure will not be available. Given that such a study is questionable from an ethical point of view, clinical decisions for this select group of patients must be done on a case-by-case basis. The best that can currently be done is to carefully follow these patients and scrutinize existing data to ensure optimal clinical management.