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Page 2 of 8 Radhakrishnan et al. Vessel Plus 2019;3:36 I http://dx.doi.org/10.20517/2574-1209.2019.23

Keywords: Coronary endarterectomy, coronary artery disease

INTRODUCTION
Primary coronary endarterectomy without coronary artery bypass grafting (CABG) was first introduced
[1-3]
in 1957 by Bailey for the treatment of acute myocardial infarction . Subsequently, endarterectomy was
combined with CABG alone, and later by vein patch and left internal mammary (LIMA) bypass of the left
[4-8]
anterior descending artery (LAD) . Initial published reports showed a high incidence of perioperative
mortality and ischemia [9-13] . This led to reluctance in performing coronary endarterectomy. The adverse
outcomes have resulted in some patients with severe and diffuse left-sided disease denied complete
surgical revascularization. The use of dual antiplatelet therapy (aspirin and clopidogrel) has been shown
to improve graft patency. Which led reduce major adverse cardiovascular events. The combination of both
may improve survival following CABG [14,15] . We aim to assess the early and late results of left coronary
endarterectomy (LCAE). Which we used as an essential step in CABG. We also combined surgery with
dual antiplatelet therapy post-op (aspirin and clopidogrel).

METHODS
We included Patients with no option for percutaneous coronary intervention (PCI) and were rejected for
conventional CABG. The rejection was because angiographically patients had atheroma involving < 80%
of the length of the coronary artery. These patients underwent CABG with LCAE at a university teaching
hospital by a single surgeon from February 1999 to September 2007. We identified the patients from a
prospectively collected database. We compared this group with a propensity-matched cohort (to allow
matching patients characteristics and risk profile) from the same period operated on by the same surgeon
in the same hospital. Information regarding pre-operative status was gathered from the clinical database.
Also, the clinical notes were reviewed retrospectively for these patients. Post-operative data were obtained
from the clinical database, clinic letters and GP surgery data. If the clinical records were not adequate,
the patient’s general practitioner was contacted by phone or e-mail. Table 1 summarizes the pre-operative
patient demographics of the study patients. The mean follow-up of the patients was for five years (Range
0-10 years).

LCAE was performed on occluded or nearly occluded vessels with multiple and long distal stenoses.
Patterns of atherosclerosis were identified pre-operatively, but the decision to perform endarterectomy was
made intra-operatively. The surgeon decided on technical consideration in combination with angiographic
features. Off-pump CABG cases were included in both the groups (CABG = 28/75, LCAE = 13/87). The
methods of myocardial protection techniques were comparable in both groups. Core temperatures were
maintained between 30 degrees to 32 degrees during cardiopulmonary bypass.

All coronary endarterectomies were performed manually. A Watson-Cheyne dissector was used to
develop a plane between tunica media and the core of the atheromatous plaque. The site for arteriotomy
was chosen, and the decision to do endarterectomy was made if the artery was almost entirely or wholly
occluded, or if the vessel wall contained heavily calcified plaques. Arteriotomy was extended as required
(2.5-9 cm) and Watson-Cheyne dissector used to develop the plane, and gentle graduated traction was
used to tease off the atheromatous core from the distal end of the vessel [Figure 1]. If the distal end of the
atheroma was not tapered, then the arteriotomy was extended until a satisfactory result was obtained, but
no attempt was made to extract the atheromatous core from the individual branches of the artery. A vein
patch was used in all the cases. The conduit was anastomosed end to side to the vein patch in all the cases.