Optimal Method of Coronary Endarterectomy for Diffusely Diseased Coronary Arteries

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ptimal Method of Coronary Endarterectomy foriffusely Diseased Coronary Arteries

iroyuki Nishi, MD, Satoru Miyamoto, MD, Shuichiro Takanashi, MD,irokazu Minamimura, MD, Takumi Ishikawa, MD, Yasuyuki Kato, MD, andoshihiro Shimizu, MDepartment of Cardiovascular Surgery, Osaka City General Hospital, Osaka, and Department of Cardiovascular Surgery, Shin-
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Background. Although several techniques for coronaryrtery bypass grafting have been introduced that incor-orate coronary endarterectomy (CE), there is little infor-ation about late patency among the various CE meth-

ds. To clarify the quality of CE, we assessed clinical andngiographic results of our experience with this proce-ure on 127 patients who had diffusely diseased coronaryrteries.Methods. Between January 1994 and December 2002,

27 patients underwent coronary artery bypass graftingith CE. Sixty-eight patients undergoing CE with long

rteriotomies and on-lay patch bypass grafting (group O)ere compared with 59 patients undergoing CE with the

onventional pull-out method (group P).Results. Thirty-day mortality was 2.9% in group O and

.8% in group P. The early angiographic results of 115

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urgery, Osaka City General Hospital, 2–13–22, Miyakojimahondori,iyakojima-ku, Osaka, 534–0021, Japan; e-mail: [email protected].

2005 by The Society of Thoracic Surgeonsublished by Elsevier Inc

atients revealed a patency rate of 92.1% (grade A: 79.4%)n group O and 88.6% (grade A: 68.6%) in group P.ctuarial survival at 5 years was 90.7% in group O and

4.0% in group P (p � 0.1). Angiograms performed on 78atients after a mean period of 21 � 16 months showed aatency rate of 89.1% (grade A:76.1%) in group O and1.0% (grade A: 38.1%) in group P (grade A: p < 0.001).

Conclusions. The midterm angiographic results of CEith long arteriotomies and on-lay patch bypass graftingere better than the results obtained with the conven-

ional pull-out method. This procedure was found to beafe and effective for complete revascularization in pa-ients with a severely and diffusely diseased coronaryrtery.

(Ann Thorac Surg 2005;79:846–53)
© 2005 by The Society of Thoracic Surgeons
he progressive application of noninvasive methods toachieve myocardial revascularization has contrib-

ted to the selection of patients with distinctly lessttractive anatomic substrates for surgery. With recentdvances in percutaneous catheter intervention such astents, the results of percutaneous catheter interventionre now improving, and some reports show the sameortality for multivessel disease with percutaneous cath-

ter intervention and coronary artery bypass grafting [1].oreover, the lesions of coronary arteries treated surgi-

ally have become more severe [2], and the populationeferred for revascularization is increasingly character-zed by advanced age and coexisting diabetes mellitusnd lipid disorders [3]. Several studies indicate thatatients with a diffusely diseased coronary artery inhom standard coronary artery bypass grafting tech-iques cannot be performed constitute 0.8% to 25.1% ofll patients with coronary artery disease [4–7]. Coronaryndarterectomy (CE) was first described by Baily andssociates, in 1957 [8], as a method of treating coronaryrtery disease without using cardiopulmonary bypassnd coronary artery bypass grafting. This procedure waseported to have high postoperative morbidity and mor-

ccepted for publication June 16, 2004.

ddress reprint requests to Dr Nishi, Department of Cardiovascular

ality during the 1960s and 1970s [9, 10]; as a result, CEame under scrutiny and its feasibility was controversial6]. However, with the recent trend of treating more casesf diffuse coronary artery disease, increasingly indicatedurgical therapy for severe and diffuse coronary arteryisease has resulted in a revival of interest in CE [3,1–19]. In an effort to expand surgical options for theseatients, several techniques have been introduced, in-luding CE and different methods for reconstructingndarterectomized vessels [11, 13, 15, 18]. However, theres little information available about the angiographicesults of endarterectomized vessels [14, 15, 18].

In 1994, we introduced this method as an adjunct tooronary artery bypass grafting and have been develop-ng and evaluating it angiographically for 10 years. Tolarify the optimal method of CE, we reviewed the resultsf recatheterization in our experience with 127 patientsho had diffusely diseased coronary artery necessitating

oronary artery bypass grafting with CE.

atients and Methods

tudy Populationhis study includes 127 patients with diffusely diseasedoronary artery requiring operation for myocardial re-ascularization between January 1994 and April 2003 at
saka City General Hospital. The mean age of the
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847Ann Thorac Surg NISHI ET AL2005;79:846–53 OPTIMAL METHOD OF CORONARY ENDARTERECTOMY

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atients was 63.8 � 8.8 years, and 34 patients (27%) wereomen. Two patients (2%) had single-vessel coronary

rtery disease, 20 patients (16%) had two-vessel disease,nd 105 patients (83%) had three-vessel disease. Theean number of distal anastomoses was 4.2 � 1.2.oronary endarterectomy was performed in 148ranches, including 71 left anterior descending arteries

LAD), 7 diagonal arteries, 17 left circumflex arteries, and3 right coronary arteries. The institutional ethics com-ittee approved this technique, and the patients signed

n informed consent before surgery.The 127 patients were divided into two groups accord-

ng to the operative method for coronary endarterec-omy. Group P, who underwent CE by the conventionalull-out method, included 59 patients. Group O, whichequired long arteriotomy and on-lay patch grafting ofhe endarterectomized vessels, numbered 69 patients.

ngiographic Protocolll surviving patients were requested for postoperative

atheterization at 1 month, 1 year, and 5 years after theperation. Postangiographic control was obtained if theatients agreed to the procedure. The quality of thenastomosis was graded according to the classification ofitzgibbon and colleagues [20]. Briefly, grade A stands forxcellent graft patency, grade B for graft stenosis ofreater than 50%, and grade O for occlusion. String sign,hich was defined as a severe and extensive narrowingf the whole body of the graft, was classified as grade Bnastomosis. The criterion for diagnosing perioperativeyocardial infarction is defined as the maximum level of

ostoperative creatine kinase myocardial band greaterhan 100 IU/L.

urgical Technique for Coronary Endarterectomyoronary artery bypass grafting was performed during

ardiopulmonary bypass with normothermia (35°C).yocardial protection was achieved by induction of

ntegrade and retrograde intermittent cold crystalloidardioplegic solution. Coronary endarterectomy was ap-lied in patients having a primary proximal significant

esion of the major coronary artery but with a diffuselyiseased or calcified coronary artery, often with involve-ent of the distal portion, which was considered not to

e amenable to other more conventional bypass grafting.essels undergoing CE were arteries supplying viableyocardium and had many segmental narrowings, so

hat anastomosing one segment would not adequatelyevascularize the territory of that vessel. Most of the CEas scheduled before operation, but the final decision of

pplying which technique was made during the opera-ion according to the surgeon’s preference.

The pull-out method (group P) was simple, as de-cribed previously [21]. A short arteriotomy was made,nd the closed traction method was applied in a mannerhat included the proximal and distal branches. Then,ypass grafting was performed to the arteriotomy. Foremoving as much plaque as possible, two or threerteriotomies were sometimes made distally to pull out
ore atheromatous core. Bypass grafting was anasto- g
osed to the most proximal arteriotomy, and the othersere closed with a patch.In group O, the long arteriotomy was extended until

ondiseased arterial lumen was reached. The coronaryrtery at the level of the first major proximal lesion waseither opened nor reconstructed to avoid competitiveow between the bypass graft and the native coronaryrtery. Coronary endarterectomy was routinely per-ormed through an extended arteriotomy, permittingxtraction of material from the origins of septal perfora-ors and diagonal branches under direct vision. Afterxing the distal coronary artery intima, on-lay patchnastomosis using the internal thoracic artery (ITA) oraphenous vein graft was constructed over the arteriot-my, with a running suture so that the graft wall made upost of the reconstructed vessel.Patients received anticoagulation postoperatively.

ow-molecular-weight heparin was initiated 6 hours af-er arrival in the intensive care unit. After 2 days, this waseplaced by warfarin sodium and aspirin and continuedndefinitely, maintaining an international normalized ra-io of 2.0.

ata Analysis and Follow-Upate follow-up information was obtained by postal ques-

ionnaire or telephone interview between April 1, 2003,nd June 1, 2003. Three patients were lost to follow-up,or a follow-up rate of 97.6%; mean follow-up time was 52

31 months (range, 5 to 109 months). All continuousariables are presented as mean � standard deviation.asic methods of univariate analysis included the �2 testnd Student’s t test. Actuarial estimates of morbid eventsere calculated by the Kaplan-Meier survival analysisethod and compared with log-rank tests. Values of p

ess than 0.05 were considered significant. StatView ver-ion 5.0 (SAS Institute, Cary, NC) was used for statisticalnalysis.

esults

atient Demographicsetween group O and group P there were no significantifferences in terms of patient characteristics, coronaryisk factors, preoperative comorbidities, or cardiac pro-les (Table 1). In group P, CE was performed in 76ranches, including 24 LAD, 5 diagonal arteries, 10 leftircumflex arteries, and 37 right coronary arteries. Inroup O, the sites of the CEs were LAD in 47, leftircumflex arteries in 7, right coronary arteries in 16, andiagonal arteries in 2 cases. The mean length of on-layatch bypass grafting was 4.9 � 2.1 cm. The pull-outethod tended to be most frequently performed for

rafting to the right coronary arteries. To the LAD, on-layatch grafting was the more frequent method of CE.

perative Resultshere were no intraoperative deaths. The mean number ofistal anastomoses in group O was smaller than that in
roup P (Table 2). The ITA was most often used to recon-

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848 NISHI ET AL Ann Thorac SurgOPTIMAL METHOD OF CORONARY ENDARTERECTOMY 2005;79:846–53

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truct the endarterectomized vessel in group O. On thether hand, saphenous vein graft was most often used inroup P. Operation time, cardiopulmonary bypass time,nd cross-clamp time were similar between the two groups.

The perioperative mortality rate of group O tended toe lower than that of group P (Table 3). Four patients

3%) had a perioperative myocardial infarction—in twoases of group O and in one case of group P—in theegion of the endarterectomized vessels. Twenty-oneatients (17%) required intraaortic balloon pump sup-ort. The fatal postoperative complication rates wereimilar, and there were no statistically significant differ-nces among the groups.

emote Resultshree patients were lost to follow-up. There were 20 lateeaths overall: 6 patients (9%) in group O, and 14 patients

24%) in group P, giving an actuarial 5-year survival ratefter surgery of 90.7% in group O and 74.0% in group Pp � 0.1; Fig 1).

Among the living patients, the follow-up ranged fromto 105 months (average, 41.7 months) in group O and

rom 5 to 109 months (average, 64.6 months) in group P.ong-term, 85.2% of patients in group O and 76.6% inroup P were free from angina or congestive heart

able 1. Preoperative Patient Characteristics

ariableGroup O(n � 68)

Group P(n � 59)

pValue

linical demographicsAge (y) 64 � 9 63 � 8 NSAge �75 y 11 3 NSFemale sex 21 13 NS

oronary risk factorsHypertension 46 38 NSDiabetes 38 33 NSHyperlipidemia 38 34 NSSmoking 33 32 NS

omorbidityPeripheral vascular disease 6 5 NSCerebral vascular disease 14 10 NSDialysis 4 2 NS

ardiac profilePrevious myocardial

infarction44 44 NS

History of congestive heartfailure

24 25 NS

Poor ejection fraction(�0.30)

5 7 NS

Mean ejection fraction 0.46 � 0.12 0.48 � 0.16 NSEmergent surgery 5 NSLeft main disease 14 6 NSNumber of diseased

vessels2.8 � 0.5 2.9 � 0.3 �0.05

roup O � on-lay patch bypass grafting; Group P � pull-out meth-d; NS � not significant.

ailure.Go

ngiographic Studyarly angiographic control was obtained in 60 patients

95%) with 63 anastomoses of endarterectomized vesselsn group O and in 55 patients (93%) with 70 anastomosesn group P (Table 4). Most of the grafts in group O had aumen with an acceptable width that did not have ectaticr narrow segments that would result in poor flowharacteristics (Fig 2A). In the early angiographic results,he grafts in group P also demonstrated acceptable widthFig 3A).

At midterm follow-up, information regarding angio-raphic control was obtained from survivors of group Omean, 20 � 15 months; range, 12 to 65 months) and ofroup P (mean, 24 � 19 months; range, 12 to 66 months).he rate of grade A anastomosis (stenoses or occlusion-

ree anastomoses) was 76.1% in group O and 38.1% inroup P, demonstrating a significant difference (p � 0.05).

able 2. Operative Characteristics


Group P(n � 59)

pValue

umber of distal anastomoses 4.0 � 1.3 4.5 � 1.1 �0.051 2 02 5 03 17 124 23 165 12 21�5 9 10

ross-clamp time (min) 141 � 31 140 � 27 NSardiopulmonary bypass time(min)

195 � 48 201 � 40 NS

perative time (min) 391 � 95 408 � 74 NSonduit to endarterectomizedvesselsInternal thoracic artery 54 26Radial artery 1 2Saphenous vein 29 36Gastroepiploic artery 0 1


able 3. Perioperative Mortality and Morbidity


Group P(n � 59) p Value

eath (30-day) 2 (2.9%) 4 (6.8%) NSntraaortic balloon pump 8 13 NS

Preoperative 4 6Postoperative 4 7ajor complications 7 9 NSPerioperative myocardial

infarction2 2

Reexploration for bleeding 3 3Cerebral vascular accident 2 0Infection 2 4


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hereas the midterm rate of grade A anastomosis inroup O was not different from that of the early postop-rative stage, the rate of grade A anastomosis in group Pignificantly dropped from the early period to the mid-erm. Most patients in group P had patent CE segmentsith a thin or absent lumen of the distal coronary artery,

nd the grafts were still patent despite poor runoff (FigB). On the other hand, most of the endarterectomizedessels in group O had excellent patency even severalears after the operation (Fig 3B).In 21 patients of the conventional group (group P),

ypass grafting was anastomosed to the most proximalrteriotomy, and the rest were closed with a patch. Earlyerm and midterm graft patency rate in that group were6.3% and 69.2%, respectively. On the other hand, earlyerm and midterm graft patency rate in the rest of group

were 92.3% and 83.3%, respectively.

ig 1. Actuarial estimates of survival after coronary endarterectomyith two different techniques. Group O � on-lay patch bypass

rafting; Group P � pull-out method. (Pts. � patients.)

able 4. Postoperative Angiographic Results


arly patency rate 92.1% (58/63)Grade A 50 (79.4%)Grade B 8

nternal thoracic artery 90.1% (38/42)Grade B 6

aphenous vein 95.0% (19/20)Grade B 2idterm patency rate 89.1% (41/46)Grade A 35 (89.1%)Grade B 6

nternal thoracic artery 93.5% (29/31)Grade B 4

aphenous vein 76.9% (10/13)Grade B 1

roup O � on-lay patch bypass grafting; Group P � pull-out method;

omment

he results of this study indicate that CE can be carriedut with an acceptable operative risk, especially when

ong arteriotomies and on-lay patch bypass grafting issed as a CE method. There are several reasons for betteresults with the on-lay patch method. First, CE can beerformed under direct vision with a long arteriotomy,xposing the whole arterial lumen and side branchesontaining atherosclerotic occlusive material, so that itecomes possible to avoid residual material in the lumens well as in the dissections. Second, on-lay patch graft-ng of the ITA consists of new coronary lumen. We madehe on-lay patch technique so that the ITA wall makes up0% of the reconstructed vessel, and the newly recon-tructed coronary artery retains 20% of the native coro-ary artery. Coronary artery reconstruction is performedy covering the arteriotomy with an ITA in such a fashions to exclude atheromatous plaques from the lumen ofhe coronary arteries. As previously reported, once CE iserformed, the resulting lack of endothelium exposes to

he flowing blood all the subendothelial material that canrigger the coagulation cascade [11, 13, 22]. Although anncomplete endothelial covering of the endarterecto-

ized arterial wall enhances myocyte proliferation, it istopped when the endothelial covering is complete. Ourechnique of on-lay patch grafting reduced the endarter-ctomized area and presented new coronary artery wall.his might achieve rapid complete endothelial coveringnd should decrease the risk of intimal proliferation. Thehird reason is the function of the ITA. This providesetter vasomotor function, particularly the capacity todjust the flow rate in proportion to the distal runoff, aidely known paracrine function of living endothelium

hat produces and releases prostacyclin and other endo-helium-dependent relaxation factors [23]. The diameterf the coronary artery is also important. The recon-tructed segment in endarterectomy is often wider than

Group P(n � 59) p Value

88.6% (62/70) NS48 (68.6%) NS

1477.0% (23/26) NS

887.5% (35/40) NS

381.0% (34/42) NS16 (38.1%) �0.05

1873.7% (14/19) NS

1085.0% (17/20) NS

6

NS � not significant.

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he native artery and this depends on both the graftingechnique and the graft material [11]. In cases of bothaphenous vein patch reconstruction and ITA grafting,nadequate flow through the graft (associated with anrregular and patulous vein patch) was reported [18]. Ourechnique of CE using ITA on-lay patch can provide aetter match in diameter with the graft, the reconstructedegment, and the native coronary artery, resulting inetter flow patterns.In the previous study, early postoperative mortality

fter CE was reported to be higher than for simpleoronary artery bypass grafting [3, 11–19]. Although earlyortality has improved with recent advances in CE

echniques (to between 1.2% and 10.1%), it still remainsigher because of the more advanced coronary arteryisease that it treats [17]. Most authors report that CE isnly used for complex reconstructions or for patientsith end-stage coronary artery disease, and that CEatients required more bypass grafts [3, 13, 16, 17]. Thisuggests that there is a significant bias in the selection ofE patients. The fact that CE patients have far-advanced,

ig 2. (A) Coronary angiography at 1onth in a patient with a 4.5-cm long end-

rterectomy and on-lay patch bypass graft-ng of the internal thoracic artery to the leftnterior descending coronary artery. Regu-ar walls and a lumen with an acceptableidth can be observed. (B) The reconstruc-

ion site became smoother and still pre-erved a lumen with an acceptable width 41onths after the operation. Good filling of

eptal perforators is also noticeable.

ig 3. (A) Coronary angiography of a pa-ient undergoing the conventional pull-outethod of carotid endarterectomy, at the

arly postoperative stage. The lumen at thendarterectomy and reconstruction site isrregular and patulous. (B) The reconstruc-ion site became irregular and showedtring signs 30 months after the operation.

omplex disease must be considered. Thus, the earlyostoperative mortality in our series was acceptable,specially in the case of on-lay patch reconstruction.Perioperative myocardial infarction is one of the more

erious problems arising during the performance of CE:revious studies have reported a higher rate than fororonary artery bypass grafting alone. With recent ad-ances in the CE technique, the perioperative myocardialnfarction rates have improved and now range from 1.5%o 8% [3, 11–19]. Because of the long arteriotomy, it oftenakes more time to achieve on-lay patch grafting than toerform CE by the conventional method. Extensive end-rterectomy and construction of a long anastomosis areikely to take longer than the 20 minutes usually availableetween cardioplegia infusions [13]. This problem isore significant when CE is performed on the LAD. To

void fatal perioperative myocardial infarction, CE waserformed with antegrade and retrograde cardioplegicrrest. Care was taken to avoid bleeding from the ante-ior interventricular vein so as to obtain adequate retro-rade cardiomyocyte protection. These techniques ex-

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ended the limits of safe arrest and the optimalonditions for endarterectomy and multivessel grafting.s a result, a favorable rate of perioperative myocardial

nfarction could be achieved in the case of on-lay patchrafting.Our late results (5-year actuarial survival) for patientsith on-lay patch reconstruction was better than those

or patients who underwent the conventional CE tech-ique. This feature was probably a reflection of theomplete removal of all atherosclerotic material and theomplete revascularization of the endarterectomized ves-els in group O patients.

The size of our angiographic study in CE patients wasarger than in previous studies [11, 12, 15, 17, 18, 24, 25].ecause most of the patency quoted in the literature

nvolved selective restudy of certain subgroups of theriginal cohort, the only way to obtain a true picture ofhe natural history of endarterectomized grafts was to useoth early and late coronary angiography to study, pro-pectively, a consecutive group of patients. In the litera-ure, the patency rate of CE at 1 year is between 56% and8% [4–6, 26]. This is dependent on CE technique and onhether or not threadlike arteries are considered to

epresent graft failure. About 10% of our patent casesere ranked as grade B in the early postoperative stage.ome of these included stenosis of the graft with patencyf the native coronary artery in which the proximally

ig 4. Evaluation of the status of the intima by intravascular ultra-ound sonography at the early and late postoperative stages. In theull-out method, although the diameters of endarterectomized vesselsere wide in the early postoperative stage (A), they became narrows a result of intimal hyperplasia in the late postoperative stage (B).n the other hand, intimal hyperplasia rarely occurred in group P,

ven in the late postoperative stage. The intima of the internal tho-acic artery became circumferential, and intima was reconstructed inhe endarterectomized vessels: (C) early, (D) late.

xtended CE had removed all the stenoses. Of course,

ncomplete removal of atheromatous plaque might alsoause this phenomenon. There is little information onate graft patency, with rates ranging from 40% to 81.5%11, 17, 19, 24]. Our late patency rate in the on-lay patchroup was better than those previously reported and wascceptable when compared with the patency rate oflassic ITA bypass grafts on nondiffuse coronary arteryesions [27]. Coronary endarterectomy with the on-layatch method does not increase the rate of graft failureespite the presence of diffuse coronary lesions.In our angiographic study, long arteriotomy and ITA

n-lay patch grafting is considered to be the preferredethod after CE is performed for diffusely diseased

oronary artery. Although the number of midterm gradeanastomoses in the on-lay patch group did not differ

rom the early postoperative stage, the rate of grade Anastomoses in the conventional CE method droppedignificantly. These changes may be owing to the devel-pment of myofibrointimal proliferation and localizedtheroma in the conventional CE method group. In thetudy on the status of the intima by intravascular ultra-ound sonography, although the diameter of endarterec-omized vessels was wide in the early postoperativetage, it became narrow as a result of intimal hyperplasian the late postoperative stage (Figs 4A, 4B). On the otherand, intimal hyperplasia rarely occurred in the on-layatch group, even in the late postoperative stage. In the

ntravascular ultrasound sonography study, the intima ofhe ITA became circumferential, and new intima wasonstructed in the endarterectomized vessels (Figs 4C,D). This coronary reconstruction may be the reasonehind the good results in this group. The conventionalroup included fewer patients receiving endarterectomyo the LAD. However, we do not consider that thisccounts for the inferior results in the conventional groupecause there were no obvious differences of graft pa-

ency of ITA or saphenous vein graft between group Ond group P. Moreover, there were no obvious differ-nces of graft patency between ITA and saphenous veinraft in the two groups.The indication of CE is also important. We consider

hat elective CE should be reserved only for arteries thatre truly inoperable by other means and for instances inhich the involved vessel supplies a coronary bed of at

east moderate size, so that failure to graft the vessel at allould be expected to result in residual angina. Vesselsith extensive noncalcific atheroma and a small lumen,ith a severely diseased distal right coronary artery withultiple small branches, might also be indications forE. A prospective randomized trial will be needed torove the superiority of the on-lay patch method; this is

he limitation of the present study. Because we nowoutinely perform CE with the on-lay patch techniquewing to the superiority of this method, the fate ofndarterectomized grafts should be followed carefully.

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NVITED COMMENTARY

everal studies indicate that patients with diffuse coro-ary artery disease in whom standard coronary bypass

echniques cannot be performed constitute up to 25% ofll patients with coronary artery disease. In the modernra of invasive interventional cardiology, the referralumber of patients with diffuse coronary artery diseaseill continue to increase. Therefore, the present study byishi and colleagues offers some major contributions to

oronary surgery, by providing valuable early and lateostoperative angiograms of patients with coronary end-rterectomy. The authors should be congratulated forheir high rate of postoperative angiographies whicheached more than 80%.

The most important finding of this study is that withpen endarterectomy and on-lay patch grafting, the ratef grade A anastomosis (free of stenosis or occlusion) atid-term angiographic studies was not different from

osis in conventional pull out endarterectomy groupignificantly dropped from early to mid-term. This is aemarkable finding and should be kept in mind whileperating with diffusely diseased coronary arteries.While describing the conventional pull out method,

he authors mention application of closed traction foristal and proximal branches. According to our experi-nce, proximal dissection plane should end at the end ofhe arteriotomy and plaque should be transected at thisoint. Blind proximal endarterectomy, particularly on the

eft anterior descending artery, may disrupt flow intoajor proximal branches, including the circumflex ar-

ery, a ramus artery or septal arteries.One other technical issue, although not advocated but

erformed by the authors needs some discussion. Somef the conventional endarterectomy patients in this studyad more than one arteriotomy. Bypass grafts were
nastomosed to the most proximal arteriotomy and the
0003-4975/05/$30.00doi:10.1016/j.athoracsur.2004.07.056

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Optimal Method of Coronary Endarterectomy for Diffusely Diseased Coronary Arteries