Short- and Long-Term Patient Outcomes From Combined Coronary Endarterectomy and Coronary Artery Bypass Grafting: A Meta-Analysis of 63,730 Patients (PRISMA)

Mid-term angiographic evaluation of LIMA-LAD anastomoses following LAD endarterectomy in coronary artery bypass grafting

OBJECTIVE

Diffuse coronary artery disease remains a critical issue that heart surgeons continue to research in terms of treatment options. An alternative method applied during coronary bypass surgery to achieve complete revascularization is coronary artery endarterectomy. Since the reliability of this technique and its effects on mortality and morbidity are still debated in the literature. Our objective in conducting this study is to determine the mid-term patency rates in patients who underwent LAD endarterectomy and to explore its future applicability.

MATERIALS AND METHODS

This study reviewed 20 patients who underwent coronary endarterectomy during CABG in our clinic between January 2014 and December 2021. The data, including contrast imaging to check graft patency, were evaluated retrospectively by reviewing hospital archives and patient files. Patients without LAD endarterectomy were excluded from the study.

RESULTS

LAD endarterectomy and patch-plasty were performed on all patients in the study. In 17 patients, the LIMA graft was anastomosed onto the patch applied to the LAD. It was observed that 12 of the grafts anastomosed to the LAD (60%) were patent during a mean follow-up period of 32.8 ± 25.9 months. The average 4-year survival rate was found to be 95%. Perioperative myocardial infarction occurred in 5 patients (25%). There was no need for high-dose inotropic support, IABP, or ECMO in the postoperative period.

CONCLUSION

Coronary artery endarterectomy should be considered a viable option for surgeons to achieve satisfactory revascularization in cases where suitable anastomosis sites on coronary arteries to ensure adequate outflow are not available. Our findings align closely with literature reports indicating that endarterectomy performed on the LAD, with LIMA used as the conduit, leads to promising outcomes.

Vein Patch Angioplasty with Internal Mammary Artery Grafting of the Left Anterior Descending Coronary Artery

Objective

To describe the treatment outcomes of patients who underwent coronary artery bypass grafting (CABG) with vein patch angioplasty with internal mammary artery (IMA) grafting of the diffusely diseased left anterior descending (LAD) coronary artery.

Methods

This is a retrospective observational study of 26 patients who have undergone vein patch angioplasty of the LAD coronary artery with IMA grafting in three centers by a single surgeon from January 2012 to August 2017. The demographic profile, intraoperative data, and postoperative outcome (including in-hospital mortality and morbidity, perioperative myocardial infarction, and NYHA functional classification) were recorded. Continuous variables were expressed as means with standard deviation and categorical variables summarized as frequencies and percentages. Student's t-test was used to compare the preoperative versus postoperative mean NYHA functional class.

Results

There were 22 (85%) males and 4 (15%) females with a mean age of 62 years (range: 34 to 82). Twenty-five patients (96%) had a three-vessel disease, and one (4%) had a two-vessel disease. Nine patients (35%) had a preoperative myocardial infarction. The mean cardiopulmonary bypass and aortic-cross clamp times were 156 and 118 minutes, respectively. The mean number of vessels grafted was 4.12. Multiple arterial grafting was used in seven patients (27%). There were two in-hospital mortalities (7.7%) and three morbidities (11.5%), including reoperation for bleeding, acute kidney injury, and leg wound infection. Six patients (23%) developed postoperative atrial fibrillation. No patient developed perioperative myocardial infarction. The mean ICU stay was three days, and the mean hospital stay was 10.27 days. The mean NYHA functional class improved from 2.85 preoperatively to 1.5 postoperatively (p<0.00001). Among patients with improvement, postoperative NYHA improved by two functional classes in 38% and by one functional class in 62%.

Conclusion

Vein patch angioplasty is a valuable technique for diffuse coronary stenosis of the LAD artery with acceptable early results.

Outcomes of coronary artery bypass grafting with coronary endarterectomy: A systematic review and meta-analysis of recent studies

Objective: The aim of this systematic review and meta-analysis was to evaluate the short-term and long-term outcomes of coronary artery bypass grafting (CABG) with coronary endarterectomy (CE) versus isolated CABG.Methods: Studies evaluating outcomes of CABG with CE (CE-CABG) were searched from 1 January 2000 to 30 September 2022, on PubMed, Embase, and Cochrane databases. The primary outcome was 30 -days mortality. Secondary outcomes were postoperative myocardial infraction, low output syndrome, cardiac arrhythmia, renal dysfunction, and 5 years survival.Results: A total of 12 observational studies including 114,319 patients assessing CE-CABG (n = 35,174) versus isolated CABG (n = 79,145) were included. Compared to isolated CABG alone, CE-CABG was significantly associated with increased incidences of 30-days mortality (RR, 1.87; 95% CI, 1.73-2.07; p < 0.01), postoperative myocardial infraction (RR, 1.61; 95% CI, 1.26-2.05; p < 0.01), low output syndrome (RR, 1.54; 95% CI, 1.17-2.02; p < 0.01), and renal dysfunction (RR, 1.56; 95% CI, 1.44-1.69; p < 0.01). However, there was no difference in either rate of cardiac arrhythmia (RR, 1.06; 95% CI, 0.97-1.15; p = 0.20) or 5 years survival (RR, 1.05; 95% CI, 0.95-1.16; p = 0.34) between the CE-CABG group and the control group. Subgroup analysis on CE technique showed that CE-CABG was also associated with 30 days mortality in patients undergoing closed CE (RR, 1.49; 95% CI, 1.09-2.03), whereas this association between CE and 30 days mortality was not observed in patients undergoing open CE (RR, 1.76; 95% CI, 0.58-5.32).Conclusions: Despite poor short-term outcomes, CE-CABG appeared to offer satisfactory long-term survival in patients with diffuse coronary artery disease.

Selective coronary vein bypass graft improves outcomes of patients with right coronary artery lesion

Background

The benefits of selective coronary vein bypass grafting (SCVBG) for patients with severe diffuse lesions of the right coronary artery (RCA) who are unsuitable for coronary endarterectomy (CE) are unclear.

Methods

We recruited patients with diffuse lesions of the RCA undergoing coronary artery bypass surgery between January 2015 and December 2018 and matched SCVBG and CE patients on propensity score (PS). We evaluated the degree of single-stenosis in the RCA, incidence of perioperative myocardial infarction (MI) and major adverse cardiovascular and cerebrovascular events (MACCE), influencing factors of perioperative MACCE, long-term survival rate, and long-term MACCE incidence.

Results

Overall, 430 patients were enrolled: 344 (80%) underwent CE and 86 (20%) underwent SCVBG (n=78 and n=64, respectively, after PS matching). The incidence of perioperative MI and MACCE were significantly lower in the SCVBG group (5.1% vs. 1.5%, P<0.05; and 10.2% vs. 4.7%, P<0.05). When the vascular flow rate of the graft anastomosed to RCA in the SCVBG group was above 100 mL/min, the incidence of perioperative MACCE significantly increased [odds ratio (OR): 1.94, 95% confidence interval (CI): 1.42-2.03]. Choosing the bilateral internal mammary artery for SCVBG reduced the incidence of perioperative MACCE (OR: 0.82, 95% CI: 0.68-0.92). There was no significant difference in the rates of long-term survival or MACCE between the two groups before or after PS matching (P>0.05).

Conclusions

SCVBG is an acceptable surgical intervention for patients with severe diffuse RCA lesions.

Myocardial Perfusion Scan Study before and after On-Pump Coronary Artery Bypass Grafting Surgery - A Single-Center Study

Aim

Ischemic cardiac disease is the most common adult heart disease. The primary aim of the study was to analyze the myocardial perfusion status of the patients undergoing coronary artery bypass graft using sestamibi scan and assess the improvement in perfusion status of the myocardium after the surgery.

Materials and Methods

This study was a descriptive study consisting of a single group of patients undergoing elective surgery for coronary artery disease. The patients underwent myocardial perfusion scan before surgery. Another myocardial perfusion scan was performed 3 months after the surgery. The change in myocardial perfusion status was analyzed.

Results

Totally, 49 patients were initially included in this study. Seven patients lost their follow-up. Among the 17 patients who had severely reduced tracer uptake preoperatively, 3 (7.1%) had a good outcome, while 14 (33.3%) had a poor outcome, which was statistically significant (P < 0.001). Eighteen cases who belonged to the category of moderately reduced tracer uptake while analyzed, it was found that 16 (38.1%) had a good outcome while only 2 (4.8%) had a poor outcome; the difference in proportion among these two groups was statistically significant (P < 0.001). The patients who had mildly reduced tracer uptake preoperatively, all 3 (7.1%) had a good outcome, but it was not statistically significant (P = 0.23). Four patients had adequate tracer uptake preoperatively, out of which 3 (7.1%) had a good outcome, while the other 1 (2.4%) had a poor outcome and was not statistically significant (P = 0.63).

Conclusion

Surgical revascularization improves perfusion in a selective group of patients.

Coronary plaque burden predicts perioperative cardiovascular events after coronary endarterectomy

Background and aims

The risk factors of perioperative and long-term cardiovascular events in patients undergoing coronary artery bypass grafting (CABG) with adjunctive coronary endarterectomy (CE) are not well determined. This study evaluated the clinical value of coronary plaque burden, coronary anatomic stenosis, and serum biomarkers for predicting perioperative cardiovascular events after off-pump CABG + CE.

Methods

This retrospective cohort single-center study enrolled 125 patients undergoing off-pump CABG + CE between February 2018 and September 2021 in China. Coronary plaque burden was reflected by the length of plaque removed by CE. Plaque length-max, which represents the plaque length in patients undergoing single-vessel CE and the maximum plaque length in patients undergoing multivessel CE, was calculated. The primary endpoint was perioperative myocardial infraction (PMI).

Results

Plaque length-max was significantly higher in patients with PMI than in those without PMI (2.4 ± 1.5 vs. 1.6 ± 0.9, p = .001). A threshold plaque length-max of 1.15 cm was an independent predictor of PMI (area under the curve: 0.67; sensitivity 87.9%; specificity 59.8%; p = .005). Patients with plaque length-max ≥1.15 had a > 5-fold increase in PMI after adjusting for confounding factors (odds ratio = 5.89; p = .002). Furthermore, interleukin-6 (Beta = .32: p = .028), CD68 (Beta = .34; p = .045), and osteopontin (Beta = .43; p = .008) were significantly correlated with plaque length-max.

Conclusions

Plaque length-max was superior to clinical cardiovascular risk factors in predicting PMI occurrence after off-pump CABG + CE, which might be associated with systemic and plaque inflammation state.

Role of Antiplatelet Therapy in Patients with Severe Coronary Artery Disease Undergoing Coronary Artery Endarterectomy within Coronary Artery Bypass Surgery

Background—Coronary endarterectomy (CEA) has been introduced to allow revascularization in end-stage coronary artery disease (CAD). After CEA, the injured remnants of the vessel’s media could result in fast neo intimal tissue ingrowth, which require an anti-proliferation agent (antiplatelet therapy (APT). We aimed to review outcomes of patients undergoing CEA within bypass surgery who received either single-APT (SAPT) or dual-APT (DAPT). Methods—We retrospectively evaluated 353 consecutive patients undergoing CEA within isolated coronary artery bypass grafting (CABG) in the period 01/2000–07/2019. After surgery, patients received either SAPT (n = 153), or DAPT (n = 200) for six months then lifelong SAPT. Endpoints included early, late survival, and freedom from major-adverse-cardiac and cerebrovascular events (MACCE), which were defined as incidence of stroke, myocardial infarction, need for coronary intervention (PCI or CABG) or death for any cause. Results—Patients’ mean age was 67 ± 9.3 years; they were predominantly male 88.1%. Both DAPT- and SAPT-groups had the same extent of CAD (mean SYNTAX-Score-II: 34.1 ± 11.6 vs. 34.4 ± 17.2, p = 0.91). Postoperatively, no difference between DAPT- and SAPT-groups was reported in the incidence of low-cardiac-output syndrome (5% vs. 9.8%, p = 0.16), revision for bleeding (5% vs. 6.5% p = 0.64), 30-day mortality (4.5% vs. 5.2%, p = 0.8) or MACCE (7.5% vs. 11.8%, p = 0.19). Imaging follow-up reported significantly higher CEA and total grafts patency (90% vs. 81.5% and 95% vs. 81%, p = 0.017) in DAPT patients. Late outcomes within 97.4 ± 67.4 months show lower incidence of overall mortality (19 vs. 51%, p < 0.001) and MACCE (24.5 vs. 58.2%, p < 0.001) in the DAPT patients when compared with SAPT patients. Conclusions—Coronary endarterectomy allows revascularization in end-stage CAD when the myocardium is still viable. The use of dual APT after CEA for at least six months seems to improve mid-to-long-term patency rates and survival, and reduced the incidence of major adverse cardiac and cerebrovascular events.

Drug-coated balloon angioplasty, intraoperatively through left anterior descending arteriotomy access, a novel hybrid revascularization strategy: a case report

Background

Patients undergoing coronary artery bypass graft (CABG) sometimes have critical proximal lesion in left anterior descending (LAD) artery or chronic total occlusion followed by either skip lesions or diffuse disease of late mid-to-distal LAD artery. Such lesions require endarterectomy or atheroma bridging via long venous or arterial patch (patch-plasty), for which clinical outcomes are conflicting in studies due to a more thrombogenic milieu created by patch-plasty as well as incomplete endarterectomy. We present a hybrid approach with drug-coated balloon (DCB) angioplasty of mid-to-distal LAD through LAD arteriotomy followed by left internal mammary artery (LIMA) insertion to LAD.

Case summary

A 35-year-old man who was thrombolyzed for anterior wall myocardial infarction in another city, reported to our hospital four weeks later with persistent angina. Coronary angiography showed severe multivessel coronary artery disease. There was diffuse disease in LAD distal to potential site of LIMA insertion and needed patch-plasty. We carried out a hybrid procedure by performing DCB angioplasty of mid-to-distal LAD through the LAD arteriotomy site during CABG followed by LIMA insertion to the LAD. The patient remained asymptomatic post procedure with a 6-month follow-up computerized tomography scan showing patent LIMA and mid-to-distal LAD.

Discussion

This case shows a novel technique, first in the world, of performing angioplasty during CABG through arteriotomy followed by graft insertion.

Outcomes of Patients Undergoing Closed Traction CoronaryEndarterectomy: A Long-Term Single Center Study

Background-Coronary endarterectomy (CEA) is an option for treating severely diffused coronary artery diseases; however, many surgeons avoid performing it due to its complexity and reported controversial results. Therefore, we aimed to review the results of patients undergoing CEA within coronary artery bypass grafting (CABG). Methods-This is a retrospective observational study evaluating the results of patients undergoing CEA within CABG surgery between March 2003 and February 2018. Follow-up via active personal and/or telephone interviews was performed to evaluate long-term clinical outcomes. The study endpoints included early postoperative incidence of myocardial infarction or cardiac mortality, long-term survival, and freedom from major adverse cardiac and cerebrovascular events (MACCE). Results-A total of 326 patients were included in this study for evaluation. The patients' mean age was 67 years; 88% were male, and most presented with three-vessel disease, reporting a mean SYNTAX score of 33.1 ± 12. Approximately 5.5% (n = 18) of the patients had undergone previous CABG surgery. A total of 394 CEAs within a mean of 4.3 ± 1.1 grafts per patient were performed. The indication for CEA was either totally (n = 111, 28.2%) or sub-totally (n = 283, 71.8%) occluded coronary arteries. Early results included perioperative myocardial infarction in eight (2.4%), stroke in eight (2.4%), and in-hospital mortality in thirteen (4.0%) patients. Long-term clinical follow-up reported mortality in 27.6% and overall incidence of MACCE in 41.4% of the patients at the ten-year follow-up. Conclusions-Patients with severe and diffuse CAD are difficult candidates for surgical revascularization. CEA offers an option to allow complete revascularization, even in the case of chronic occlusion, when the myocardium is still viable. The closed traction CEA technique presented here is our preferred method; it achieves satisfactory short- and long-term results.

[In-hospital outcomes of endarterectomy and coronary artery bypass grafting in multiple diffuse lesions of coronary arteries]

BACKGROUND

According to a series of studies, performing coronary endarterectomy in direct myocardial revascularization increases the risk of myocardial infarction and in-hospital mortality. There are no commonly accepted indications for carrying out endarterectomy, and in clinical practice this technique is used in severe diffuse lesions of coronary arteries.

AIM

The study was aimed at assessing in-hospital clinical outcomes of coronary artery bypass grafting (CABG) with the use of endarterectomy in patients with severe multiple diffuse lesions of coronary arteries.

PATIENTS AND METHODS

This was a single-centre retrospective study enrolling a total of 205 patients presenting with multiple diffuse lesions and subjected to CABG procedures. Of these, after excluding those with severe concomitant pathology (n=28), 177 were enrolled and divided into 2 groups: 76 patients during formation of a coronary anastomosis were subjected to forced endarterectomy from the native channel (Group 1, n=76) and the remaining patients to prolonged anastomosis and/or bypass grafting of distal branches of the diffusely damaged artery (Group 2, n=101). In-hospital outcomes were analysed in both groups.

RESULTS

The demographic and clinical characteristics were comparable by all parameters except for age: Group 1 patients were older (66.3±8.4 vs 63.0±8.5, p<0.05). The groups were comparable by severity of coronary lesions by both the SYNTAX Score and diffuse lesion index. The incidence of perioperative myocardial infarction during coronary endarterectomy (Group 1) amounted to 9.2% (7/71) and in the group without endarterectomy (Group 2) to 0. There were no cases of in-hospital mortality in either group.

CONCLUSION

In severe diffuse coronary lesions, endarterectomy combined with CABG makes it possible to perform adequate myocardial revascularization. Performing endarterectomy from coronary arteries is associated with an increased risk for the development of myocardial infarction, but its use is justified if it is impossible to create an anastomosis by means of other techniques.

Coronary endarterectomy in coronary artery disease: Factors affecting graft patency and survival

BACKGROUND

Coronary endarterectomy aims to improve completeness of revascularization in patients with occluded coronary vessels. The benefits of coronary endarterectomy remain uncertain. The aim of this study was to evaluate short-term surgical outcomes and factors affecting graft patency post-coronary endarterectomy.

METHODS

Between 2009 and 2019, 81 consecutive patients who had coronary endarterectomy done were evaluated for their perioperative and early results. A total of 36 patients with follow-up coronary studies were included in patency analysis. Mortality rates, major adverse cardiac and cerebrovascular events, and graft patency were outcomes of interest. Survival and risk factor analysis were performed with Kaplan-Meier and logistic regression analysis.

RESULTS

The average age of the cohort was 61.9 ± 9.29 years. Complete revascularization rate was 95.4% post-coronary endarterectomy. The 30-day and 1-year mortality was 2.5 and 6.2%, respectively. One-year major adverse cardiac and cerebrovascular events rate was 11.1%. Periprocedural myocardial infarction rate was 7.4%. Three patients required repeat revascularization within a mean follow-up duration of 49.6 ± 36.5 months. Overall graft patency was 89.2% at 20.2 months and graft patency post-coronary endarterectomy was 85.4%. Arterial grafts showed 100% patency. Vein grafts to endarterectomized obtuse marginal branch had patency rates of 33.3%. Multiple endarterectomies were associated with worse one-year major adverse cardiac and cerebrovascular events (OR: 28.6 ± 1.16; P = 0.003).

CONCLUSIONS

Coronary endarterectomy facilitates completeness of revascularization and does not increase early mortality. Graft patency post-coronary endarterectomy on obtuse marginal artery was suboptimal. Judicious use of coronary endarterectomy should be practiced to balance the need of completeness of revascularization against the risk of myocardial infarction.

Distal anastomosis support for bypass grafting with coronary endarterectomy for the severe diseased posterior descending artery

BACKGROUND

The posterior descending artery is the most common vessel chosen for an endarterectomy, while endarterectomy to the posterior descending artery is associated with decreased graft patency. The purpose of this study was to describe a distal anastomosis support (DAS) technique and retrospectively investigate the effect of DAS on the mid-term graft patency.

METHODS

Between January 2016 and December 2018, 200 patients with a PDA severe lesion who underwent off-pump coronary artery bypass (OPCAB) with CE (OPCAB + CE group, n = 95) and OPCAB + CE with DAS for anastomosis of PDA grafted by saphenous vein (SVG) (OPCAB + CE + DAS group, n = 105) were evaluated retrospectively. All patients came back to follow-up visit 6th, 12th, 24th, and 36th postoperative month. The primary endpoint is the graft failure (FitzGibbon B or O) of SVG-PDA on the follow-up CTA or CAG.

RESULTS

There was no significant difference in perioperative outcomes. We found significantly improved cumulative graft patency in OPCAB + CE + DAS group at 36 months after operation (84.6% vs 76.5%, p = 0.02). In multivariate Cox regression analysis, plaque length larger than 2 cm (hazard ratio [HR], 13.108, 95% confidence interval [CI], 2.842-60.457, p = 0.001), and peak TNI ⩾70× ULN within 48 hours of surgery (HR, 3.778, 95% CI, 1.453-9.823, p = 0.006) were independent predictors of graft failure, whereas PDA diameter greater than 1.5 mm (HR, 0.231, 95% CI, 0.081-0.654, p = 0.006), and DAS use (HR, 0.336, 95% CI, 0.139-0.812, p = 0.015) were significant protective factors.

CONCLUSIONS

Concomitant DAS conferred superior mid-term patency of SVG-PDA. Adding the DAS procedure to OPCAB + CE may be a promising surgical option for patients with a PDA severe lesion, especially when PDA diameter less than 1.5 mm and plaque length greater than 2 cm.

Short-term outcomes of reconstruction of extensively diseased left anterior descending artery with or without endarterectomy: a propensity score analysis

Background

Surgical management of extensively diseased left anterior descending artery (LAD) is challenging. Reconstruction of the LAD with endarterectomy may lead to intimal disruption and affect the outcomes of surgery. We aimed to compare hospital outcomes of surgical reconstruction of extensively diseased LAD with and without endarterectomy.

Results

This retrospective multicenter study included 275 patients who had reconstruction of extensively diseased LAD from 2015 to 2019. We divided patients into two groups: group 1 (n = 138) included patients who had plaque exclusion and patching, and group 2 (n = 137) included patients who had endarterectomy and patching. All patients had primary isolated on-pump coronary artery bypass grafting with the left internal mammary artery (LIMA) grafting to LAD. On-lay LIMA patch was used in 118 patients in group 1 and 132 patients in group 2. A saphenous vein patch was used in 20 patients in group 1 and 5 patients in group 2. Propensity score matching identified 100 matched pairs. The age in group 1 was 56.1 ± 7.8 years versus 55.2 ± 7.1 in group 2 (P = 0.34). There were 119 (86.2%) males in group 1 and 113 (82.5%) in group 2 (P = 0.39). After matching, there was no difference in preoperative and operative data. In the matched groups, low cardiac output occurred in 6 (6%) patients in group 1 and 4 (4%) patients in group 2 (P = 0.73). There was no difference in mechanical ventilation time between groups (9 (25th- 75th percentiles: 7.5–14) hours in group 1 vs. 9 (7–14) hours in groups 2; P = 0.93). Length of hospital stay was 7 (6–9) days in group 1 and 7 (6–10) days in group 2 (P = 0.57). Mortality occurred in one patient in group 1. We did not report early graft occlusion cases in group 1, and one patient had a myocardial infarction in group 2.

Conclusion

The outcomes after reconstructing extensively diseased LAD with endarterectomy or plaque exclusion and patching are satisfactory and comparable in both approaches.

Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting

OBJECTIVES

The aim of this study was to evaluate the mid-term outcome of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) and explore the potential risk factors for adverse events.

METHODS

A total of 208 consecutive patients underwent CE between 2008 and 2018 in our centre, of which 198 were included in this retrospective cohort study. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs). Kaplan-Meier analysis was performed to evaluate event-free survival, whereas subgroup analysis and Cox regression were used to explore risk factors for the outcomes.

RESULTS

The median follow-up time was 34.7 months. CE + CABG was performed mainly on the left anterior descending artery (42.3%) or right coronary artery (42.3%). Both operative mortality and incidence of perioperative myocardial infarction were 1.5%. The overall survival at 3 and 5 years was 98.0% and 95.9%, whereas the MACCE-free survival was 93.7% and 89.4%, respectively. No significant difference in the incidence of MACCE was observed between on-pump and off-pump CE (P = 0.256) or between left anterior descending artery and non-left anterior descending artery endarterectomy (P = 0.540). Advanced age (>65 years) was associated with a higher risk of MACCE both in univariate [hazard ratio (HR) 3.62, 95% confidence interval (CI) 1.37-9.62; P = 0.010] and multivariate analysis (HR 3.59, 95% CI 1.32-9.77; P = 0.013).

CONCLUSIONS

When performed by experienced surgeons, CE + CABG could be an acceptable approach to achieve complete revascularization of diffusely diseased coronary arteries with satisfactory outcomes, although advanced age might increase the risk of MACCE.

Intraoperative intra-aortic balloon pump improves 30-day outcomes of patients undergoing extensive coronary endarterectomy

BACKGROUND

The efficacy of intra-aortic balloon pump (IABP) has been proven in high-risk patients undergoing coronary artery bypass grafting (CABG). However, data on the timing and benefits of IABP support in diffuse coronary artery disease after CABG combined with coronary endarterectomy (CE) remain scarce. This retrospective study assessed the effect of intraoperative or postoperative IABP on 30-day outcomes of off-pump CABG+CE.

METHODS

From January 2012 to December 2018, 546 patients undergone off-pump CABG+CE were divided into control group (n = 437) and IABP group (n = 109). Risk factors for 30-day outcomes were evaluated. Subgroup analysis from IABP group was conducted to identify the effect of timing IABP on 30-day outcomes.

RESULTS

CE on left anterior descending branch of coronary artery (LAD) (OR = 3.079, 95% CI 1.077-8.805, P = 0.036), CE with≥2 vessels (OR = 9.123, 95% CI 3.179-26.033, P < 0.001) and length of atherosclerotic plaque ≥3 cm (OR = 16.017, 95% CI 5.941-43.183, P < 0.001) were independent risk factors for postoperative acute myocardial infarction (AMI) and 30-day mortality. Comparing with intraoperative IABP support, postoperative IABP support (OR = 3.987, 95% CI1.194-13.317, P = 0.025) was closely associated with postoperative AMI and 30-day mortality.

CONCLUSIONS

For patients undergone off-pump CABG and extensive CE (CE on LAD, CE ≥2 vessels and length of atherosclerotic plaque ≥3 cm), intraoperative IABP support may improve 30-day outcomes.

Does the site of coronary endarterectomy have an impact on the clinical outcomes and graft patency?

OBJECTIVES

To explore whether coronary endarterectomy (CE) sites have obvious impacts on the clinical outcomes and graft patency in off-pump coronary artery bypass (OPCAB).

METHODS

The patients who underwent OPCAB with CE in our unit between January 2009 and December 2016 were included. The patients and the grafts were grouped according to the CE sites. The primary end points were mid-term main adverse cardiovascular and cerebrovascular events.

RESULTS

In total, 290 patients who underwent OPCAB with CE were included. CE of the left anterior descending artery (LAD), left circumflex artery and the right coronary artery was performed in 46, 30 and 194 patients, respectively. There were 60, 42 and 217 grafts anastomosed to LAD-CE, left circumflex artery-CE and right coronary artery-CE sites in 290 patients. CE was not performed in the 20 patients requiring multivessel CE. There was no significant difference in perioperative outcomes. The average follow-up time was 51 months (12-103 months). There was no significant difference in mid-term death, main adverse cardiovascular and cerebrovascular events, myocardial infarction (MI), stroke, Canadian Cardiovascular Classification for angina class and 1-year graft patency among the 3 groups. However, the rate of New York Heart Association (NYHA) class III or IV (LAD vs left circumflex artery: 59% vs 25%, P = 0.011; LAD vs right coronary artery: 59% vs 27%, P < 0.001) was higher in the LAD group than in the other groups. These results were consistent with the Kaplan-Meier curves of freedom from the adverse events.

CONCLUSIONS

CE sites had no obvious impact on mid-term death, main adverse cardiovascular and cerebrovascular events, MI, stroke, Canadian Cardiovascular Classification for angina class and 1-year graft patency in patients who underwent OPCAB with CE. The patients undergoing LAD-CE had higher rates of NYHA class III or IV.

Off-pump onlay-patch grafting using the left internal mammary artery for a diffusely diseased left anterior descending artery: in-hospital and mid-term outcomes

BACKGROUND

The aims of this study were to evaluate the in-hospital and mid-term outcomes of the off-pump onlay-patch grafting procedure using the left internal mammary artery (LIMA) for a diffusely diseased left anterior descending artery (LAD) and to identify the risk factors for postoperative LIMA graft failure in a single-center retrospective study.

PATIENTS AND METHODS

A total of 63 patients (52 males, 65.7±9.0 years) undergoing LAD arteriotomy with or without concomitant endarterectomy, followed by reconstruction using LIMA onlay-patch at the time of off-pump coronary artery bypass grafting at our institute from January 2014 to December 2016 were reviewed. The operative mortality, major postoperative morbidity, follow-up all-cause mortality, major adverse cardiac events at follow-up, and postoperative LIMA graft patency were analyzed. The risk factors for postoperative LIMA graft failure on the basis of baseline and surgical characteristics were identified by multivariable logistic regression analysis.

RESULTS

Eighteen (28.6%) patients underwent concomitant open LAD endarterectomy. The operative mortality rate was 1.6%. Major postoperative morbidity included perioperative myocardial infarction (3.2%), low cardiac output (1.6%), and reoperation for bleeding (1.6%). During the follow-up period of 24.2±9.5 months, all-cause mortality was 1.7% and the incidence of major adverse cardiac events was 6.8%. No repeat revascularization was recorded. In total, 88.1% of LIMA grafts showed FitzGibbon grade A patency determined by noninvasive coronary computed tomography angiography during follow-up. In addition, concomitant LAD endarterectomy and intraoperative LIMA graft flow were found to be independent risk factors for mid-term LIMA graft failure by multivariable logistic regression analysis (odds ratio=2.681, 95% confidence interval: 1.314-9.856, P=0.007 and odds ratio=0.932, 95% confidence interval: 0.791-0.976, P=0.021, respectively).

CONCLUSION

Revascularization of a diffusely diseased LAD using the off-pump LIMA onlay-patch technique results in encouraging clinical outcomes with favorable angiographic results. Concomitant LAD endarterectomy and intraoperative LIMA graft flow are associated with the risk of postoperative LIMA graft failure.

Coronary endarterectomy: an old tool for patients currently operated on with coronary artery bypass grafting. Long-term results, risk factor analysis

Aim

Coronary endarterectomy (CE) may provide a useful adjunctive technique to coronary artery bypass grafting (CABG) in patients with diffuse coronary artery disease. Nevertheless, the incidence of complications still remains high, long-term results remain unclear, and no risk factors for late mortality have been completely described yet.

Material and methods

We retrospectively reviewed 90 consecutive patients (67 ±8.2 years) undergoing isolated CABG in association with CE between 2006 and 2013. Mean follow-up was 75.1 ±36.2 months (median: 84 months) and it was 100% complete (6755/6755 patient-months).

Results

Operative mortality was 4.4%, the incidence of perioperative myocardial infarction was 11%. Ten-year survival was 83.3 ±4.1%, freedom from cardiac death 92.7 ±2.9%, and freedom from major adverse cardiac and cerebrovascular events 58.2 ±10.2%. Independent predictors of late mortality were age older than 70 years at time of the surgery (p = 0.018) and chronic obstructive pulmonary disease (p = 0.036). Ten-year freedom from cardiac death was better after CE on the left descending coronary artery (LAD) (93.2 ±3.3%) in comparison to CE not on the LAD (74.6 ±10.2%), although this difference did not reach statistical significance (p = 0.102).

Conclusions

Although the incidence of perioperative myocardial infarction continues to be not negligible, in the presence of diffusely diseased coronary artery vessels CE associated with CABG appears to be a feasible adjunctive surgical tool, conferring satisfactory early and long-term outcomes. Coronary endarterectomy on the LAD confers a high probability of freedom from late cardiac death. Patients older than 70 years and those affected by a primary respiratory disease represent a new challenge on which to focus attention due to the increased risk of late death.

Outcomes after a left anterior descending artery endarterectomy in advanced coronary artery disease

BACKGROUND

Coronary endarterectomy albeit infrequently utilized remains a pivotal treatment modality for advanced atherosclerotic heart disease. Benefits of coronary endarterectomy are explored in terms of better mid-term survival, freedom of major adverse cardiac and cerebrovascular events and improved left ventricular ejection fraction.

METHODS

50 patients with coronary artery disease including extensive diffuse LAD disease underwent a left anterior descending artery endarterectomy with coronary by-pass grafting and left internal mammary artery as conduit between 2006 and 2014. Prospective evaluation was performed on an outpatient basis with physical examination, echo recordings of ejection fraction and LAD flow reserve for 24 up to 60months.

RESULTS

Study group was constituted by a male to female ratio 4:1 and mean age 62.4years old. Pre-operative characteristics included patients with age<60years old and gensini score>60 in 42.1% while patients with age>60years old had gensini score (21-60) in 63.4%. Furthermore, males were affected more severely by atherosclerosis than females. Postoperative anterior wall contractility of left ventricle was improved (56% pre-op vs. 66% post-op) and hypokinesis reduced (34% pre-op vs. 24% post-op). No deaths were recorded for a mean follow-up of 48months. Also, MACCE were recorded in 8% patients. Post-operative LAD flow reserve was normal in 66% and reduced in 33% of cases. Finally, gensini score preoperatively affects mid-term flow reserve postoperatively (p<0.05).

CONCLUSION

Coronary endarterectomy presents a viable modality that preserves myocardial function and restores LAD flow in patients with diffuse atherosclerotic LAD. Also postoperative adverse effects were minimal while mid-term flow reserve was affected by preoperative factors.