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Page 2 of 11 Elsayed et al. Vessel Plus 2018;2:39 I http://dx.doi.org/10.20517/2574-1209.2018.65

INTRODUCTION
The progressive application of percutaneous coronary interventions (PCI) to achieve myocardial
revascularization has contributed to the referral of patients with distinctly less attractive anatomic substrates
for surgery. Surgical candidates now are usually from an older age group, have more severe coronary
lesions and suffer from multiple comorbidities. Of these perhaps diffuse coronary disease is one of the most
troublesome situations the surgeon has to deal with.

A conventional anastomosis placed distally in a diffusely diseased vessel such as the left anterior descending
artery (LAD) may leave a large area of myocardium supplied by large side branches unrevascularized, which
[1]
defies the principle of coronary artery bypass grafting (CABG) aiming at complete revascularization .
Hence endarterectomy has been revisited as an adjunct to conventional CABG in such cases.

Coronary endarterectomy is done by different surgical techniques, mainly open and closed. However in
principle, they all entail removal of the atherosclerotic plaque or calcified core of the coronary vessel creating
a neo-vascular bed which can be revascularized using one of the standard arterial or venous conduits.

[2]
Since Bailey’s first coronary endarterectomy , a lot has changed, namely the use of cardiopulmonary
bypass, pharmacological support, and the growing experience of cardiac surgeons. In the current era
results have changed significantly from earlier days where controversial debates were held about coronary
[3]
endarterectomy due to its morbidity and mortality mainly perioperative myocardial infarction (MI) . It is
therefore important to focus on the current results and proper indications for selecting this technique.

In this study we evaluate the outcome of different surgical modalities for coronary reconstruction in
diffusely diseased LAD.

METHODS
Thirty patients with diffusely diseased left anterior descending coronary artery presenting to the
Cardiothoracic Surgery Department in Alexandria Faculty of Medicine from January 2016 were included
in this study and followed prospectively for at least 6 months. Informed consents were obtained from all
patients prior to the procedure with explanation regarding the aim of the procedure and the possible side
effects according to the guidelines of ethical committee at Alexandria Faculty of Medicine.

Inclusion criteria: primary elective CABG patients with diffuse LAD disease requiring endarterectomy with
or without combined valvular procedure.

Exclusion criteria: patients needing endarterectomy in diffusely diseased vessels other than the LAD.

Indications for LAD endarterectomy: (1) chronic total occlusion of the LAD; (2) heavily calcific plaque
impeding suturing of bypass graft to the coronary vessel; (3) multiple obstructions in the LAD; (4) diffusely
diseased LAD with atherosclerosis extending into major side branches; and (5) soft atherosclerotic plaque for
fear of sutures disrupting the plaque and causing distal embolization.

Surgical procedure: all procedures were done using median sternotomy and cardiopulmonary bypass.
Cardioplegia was given in antegrade fashion and temperature was allowed to drift.

The most suitable soft spot was identified for LAD arteriotomy, and arteriotomy was done using super blade.
Failure to pass 1 mm coronary probe through the arteriotomy confirmed the need for endarterectomy,
which was often anticipated from the coronary angiography and other times not. The LAD arteriotomy was
extended using the coronary scissors till a disease free area distal to the atherosclerotic plaque was identified