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Myocardial revascularization procedures on multisegment diseased left anterior descending artery: endarterectomy or
F Alamanni1, A Parolari, M Agrifoglio
1Centro Cardiologico Università degli Studi, Fondazione I Monzino, IRCCS, Milano.
Insights
For complex coronary artery disease involving the left anterior descending artery (LAD) system, the multiple sequential anastomoses (jumping) technique offers a safer alternative to coronary endarterectomy (EA), resulting in fewer complications and improved outcomes.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Vascular Biology
Background:
- Complete revascularization is the gold standard in coronary artery surgery for superior long-term results.
- Complex disease of the left anterior descending (LAD) artery may preclude standard bypass grafting, necessitating alternative techniques.
- Coronary endarterectomy (EA) and multiple sequential anastomoses (jumping) are debated complementary revascularization strategies.
Purpose of the Study:
- To compare the safety and efficacy of coronary endarterectomy (EA) versus multiple sequential anastomoses (jumping) for myocardial revascularization of the LAD system.
- To evaluate operative and postoperative outcomes in patients undergoing these alternative revascularization techniques.
Main Methods:
- A retrospective review of 53 patients with LAD system disease unsuitable for single bypass, from January 1989 to May 1992.
- Patients underwent either coronary endarterectomy (EA) (35 patients) or multiple sequential anastomoses (jumping) (18 patients).
- Preoperative, operative, and postoperative variables were analyzed and compared between the two groups.
Main Results:
- The 'jumping' group showed a higher average NYHA class, more frequent history of myocardial infarction, and greater use of nitrates preoperatively, indicating a more unstable clinical status.
- The 'jumping' technique involved statistically more anastomoses (3.8 vs. 2.7) but had similar perfusion and cross-clamp times compared to EA.
- Crucially, the 'jumping' group exhibited a statistically significant lower incidence of perioperative myocardial infarction (0% vs. 22.8%), with lower rates of inotropic drug use, intra-aortic counterpulsation, and in-hospital mortality, though these did not reach statistical significance.
Conclusions:
- Myocardial revascularization of multisegment diseased LAD systems can be safely performed using the 'jumping' technique with a low incidence of postoperative complications.
- 'Jumping' should be the preferred technique when conventional procedures fail to achieve complete revascularization.
- Coronary endarterectomy (EA) is reserved for cases with diffuse atherosclerotic cores and poor runoff precluding multiple anastomoses.
Abstract:
Complete revascularization is the primary goal in coronary surgery because of its superior long term results. However, in some patients the extent of the coronary artery disease is such that the usual coronary bypass technique may not allow to perform a complete myocardial surgical revascularization and, consequently, a satisfactory myocardial perfusion: so complementary revascularization techniques may become mandatory, especially when the diseased vessel is LAD or its branches. As a consequence, alternative procedures should be undertaken: coronary endarterectomy (EA) and multiple sequential anastomoses on a single vessel (jump), which guidelines are actually somehow controversial. Between January, 1989, and May, 1992, 53 patients underwent a myocardial revascularization procedure on LAD system unsuitable for single distal bypass; of them 35 (66%) underwent coronary endarterectomy, while in 18 (34%) multiple sequential anastomoses (jumping) were performed on the same vessel. About preoperative variables, average NYHA class (2.7 jump vs 2.1 EA group, p < 0.05), the history of more than 1 myocardial infarction (22.2% jump vs 2.9% EA, p < 0.04) and the presence of preoperative nitrates e.v (33.3% vs 8.6%, p < 0.04) were statistically higher in the jump group, suggesting a more unstable clinical status, while other clinical echocardiographic and catheterization features were not statistically different. For what operative and postoperative features are concerned, the number of anastomoses performed was statistically higher in the jump group, as exasperated (3.8 vs 2.7, p < 0.002) while perfusion (138 vs 141 min) and crossclamp time (103 vs 106 min) were similar. Furthermore we found a statistically lower incidence of perioperative myocardial infarction (0% jump is 22.8% EA group, p < 0.04); the postperfusion inotropic drugs requirement (22.2% vs 37.1%), the need of an intraaortic counterpulsation (0% vs 2.9%) and the in-hospital mortality (0% vs 5.7%) were lower in the jumping group too, also if they didn't reach statistical significance. Our experience suggest, also with the limits imposed by a retrospective case review and by a low number of cases reported, that myocardial revascularization of a multisegment diseased LAD system may be safely performed with the jumping technique with a low incidence of postoperative complications: it should be the first choice technique when conventional revascularization procedures are not enough to achieve complete myocardial revascularization. We advocate the use of EA technique only in that cases characterized by a diffuse atherosclerotic core and a well delimited plane of dissection, associated to a very poor runoff, which really excludes any chance to multiple anastomoses.