Page 357 - Read Online

Radhakrishnan et al. Vessel Plus 2019;3:36 I http://dx.doi.org/10.20517/2574-1209.2019.23 Page 7 of 8

the use of retrograde cardioplegia and secondly the use of aggressive post-op anticoagulation with dual
antiplatelet therapy. All endarterectomy procedures were performed by an open method, and retrograde
cardioplegia was used for flushing out all the debris immediately. During beating heart surgery, the
endarterectomy was performed after application of a sling proximally, and retrograde flow used to flush the
debris before vein patching and anastomosis. Early and midterm graft failure may be due to thrombosis of
the graft itself or of the native vessel. Historically LCE was associated with an increased incidence of graft
failure and perioperative myocardial infarction [22,23] . This is likely due to exposure of the prothrombotic
and platelet aggregating promoting components of the vessel wall following endarterectomy. Dual
antiplatelet therapy, possibly by reducing early thrombotic events and platelet clumping, has been shown
to improve graft patency in off-pump surgery, following acute coronary syndromes, when multiple vein
grafts are used and in native vessel disease vessels with reduced runoff. This has translated into improved
clinical outcomes in these groups. Besides, aggressive antiplatelet administration immediately post-op with
aspirin and clopidogrel has been proven to be safe and effective after coronary artery surgery [14,24-26] . We
commenced all our patients on clopidogrel, and aspirin immediately following surgery and continued on
Clopidogrel for 1-year post-op along with lifelong aspirin.

Ideally, angiographic confirmation of graft patency would have been preferred, but the freedom from
angina in our study (91.8% at 1year and 79.4% at 10 years) along with a low incidence of perioperative
ischaemic events indirectly shows that this strategy is a valuable additional benefit for these patients.

Our results, coupled with those from other centres, suggest that coronary endarterectomy can be
accomplished safely and acceptably when applied in a particular way [27,28] . In this study, we have shown
comparable results of endarterectomy with the CABG only group when comparing long term survival
and freedom from angina. Although numerically morbidity in the endarterectomy group was slightly
higher than control, it did not have a lasting effect on long term outcome. We propose the use of left-sided
endarterectomy as a safe adjutant in dealing with diffusely diseased coronary vessel disease, especially
when long term prognosis is essential.

DECLARATIONS
Authors’ contributions
Collected and analysed the data: Radhakrishnan K
Supervised and helped writing the manuscripte: Galvin SD
Operting senior surgeon: El-Gamel A

Availability of data and materials
Data collected from King’s college and Waikato dendrite data bases.

Financial support and sponsorship
None.

Conflicts of interest
All authors declare that there are no conflicts of interest.

Ethical approval and consent to participate
The study has ethics approval from both king’s College hospital local ethics committee and waikato
hospital. All patients were consented for the study as per regulation.

Consent for publication
Not applicable.