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Ann Thorac Surg 2004;78:867-873
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Left anterior descending coronary endarterectomy: Early and late results in 196 consecutive patients

John G. Byrne, MDa,*, Alexandros N. Karavas, MDa, Tomas Gudbjartson, MDa, Marzia Leacche, MDa, James D. Rawn, MDa, Gregory S. Couper, MDa, Robert J. Rizzo, MDa, Lawrence H. Cohn, MDa, Sary F. Aranki, MDa

a Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts, USA

Accepted for publication March 8, 2004.

* Address reprint requests to Dr Byrne, Brigham & Women's Hospital, Division of Cardiac Surgery, 75 Francis St, Boston, MA 02115, USA
jbyrne{at}partners.org


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: With advances in percutaneous coronary interventions, many patients now referred for coronary artery bypass grafting have diffuse coronary artery disease. We undertook this retrospective study to determine whether left anterior descending (LAD) coronary endarterectomy is a safe and effective long-term adjunct to coronary artery bypass grafting in patients who cannot otherwise be completely revascularized.

METHODS: Between January 1992 and March 2000, 196 of 7,633 (2.5%) consecutive patients underwent LAD coronary endarterectomy with coronary artery bypass grafting. Median age was 67 years (range, 33 to 97 years), 101 patients (52%) had unstable angina, and 182 (93%) were in New York Heart Association class III or IV. Thirty-three patients (17%) had ongoing myocardial infarction; another 17 (9%) had myocardial infarction less than 1 month. Thirty patients (15%) required intraaortic balloon pump preoperatively and 19 (10%) were reoperations.

RESULTS: All patients underwent LAD endarterectomy with coronary artery bypass grafting to the LAD. The left internal mammary artery was grafted to the LAD in 151 patients (77%), and 46 of 151 (30%) of these required an additional vein patch to the endarterectomized bed. Concomitant valve procedures were performed in 8 (4%) patients. Overall hospital mortality was 3% (6 of 196). Perioperative myocardial infarction in the LAD territory was 3%. One-year survival was 94% (95% confidence interval, 90% to 97%), whereas 5-year survival was 74% (95% confidence interval, 66% to 80%). Freedom from cardiac events (angina, myocardial infarction, congestive heart failure, percutaneous coronary interventions) was 90% (95% confidence interval, 84% to 94%) at 1 year and 84% (95% confidence interval, 75% to 90%) at 5 years.

CONCLUSIONS: Despite the presence of diffuse coronary artery disease, coronary artery bypass grafting with LAD endarterectomy offers excellent results with very low hospital mortality and morbidity, and favorable long-term survival.


   Introduction
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 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Coronary endarterectomy (EA) was introduced for treating severe atherosclerotic coronary artery disease approximately 45 years ago [1], before coronary artery bypass grafting (CABG) became the standard operative treatment of myocardial ischemia. Coronary EA was shown to relieve angina symptoms, but early experiences reported high postoperative morbidity and mortality [2], and ultimately coronary EA found its role as an adjunct to CABG, mainly in patients with diffuse coronary artery disease, to afford more complete revascularization.

Most studies on coronary EA report on the right coronary artery [3]. Today many surgeons are still reluctant to use coronary EA primarily because of increased mortality and myocardial infarction (MI) rate postoperatively compared with CABG alone [4]. This has been especially the case for coronary EA of the left anterior descending artery (LAD), because of the obvious importance of the LAD with its many branches that need to be addressed during EA. With advances in percutaneous coronary interventions (PCI) many patients now referred for CABG present with more complex coronary pathologic conditions and diffuse disease. This shift makes complete revascularization more challenging. At the same time newer treatments such as transmyocardial laser revascularization [5] and angiogenic growth factor therapy [6] have been studied to offer a therapeutic alternative to patients with diffuse coronary artery disease who are not amenable for surgical treatment. In this retrospective study, we sought to determine the safety and long-term efficacy of LAD-EA in one of the largest single-institution series.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Between January 1992 and March 2000, 7,633 patients underwent CABG to the LAD artery at the Brigham & Women's Hospital. Of those, 196 patients (2.6%) underwent LAD-EA as an adjunct to CABG. After Institutional Review Board approval, a retrospective study was conducted on the 196 patients who underwent LAD-EA.

Patient demographics
Median age was 67 years (range, 33 to 87 years), and 51 of 196 (26%) patients were female. Diabetes mellitus was present in 89 of 196 patients (45%). Forty-four of 89 diabetic patients (49%) were taking oral agents whereas 45 of 89 (51%) were taking insulin. A history of smoking was present in 107 of 196 (55%). Among the smokers, 89 of 107 (83%) were current smokers whereas 18 of 107 (17%) were remote smokers. A history of hypertension was present in 132 of 196 (67%), and hypercholesterolemia in 75 of 196 (38%). Thirty-four of 196 patients (17%) had history of stroke, transient ischemic attack, or documented carotid artery stenosis 50% or higher. Twenty-one of 196 patients (11%) had known chronic obstructive pulmonary disease, whereas 28 of 196 (14%) had serum creatinine more than 1.5 mg/dL. One hundred five of 196 patients (54%) had history of old MI (>1 month), 21 of 196 (11%) had undergone prior PCI, and 19 of 196 (10%) were reoperations.

Clinical presentation
One hundred three of 196 patients (53%) presented urgently or emergently, 101 of 196 (52%) had unstable angina, and 182 of 196 (93%) were in New York Heart Association functional class III or IV. Recent MI (≤1 month) was documented in 17 of 196 patients (9%), whereas 33 of 196 (17%) underwent operation in the setting of elevated cardiac enzymes. Thirty of 196 (15%) required an intraaortic balloon pump preoperatively. Other preoperative factors are summarized in Table 1.


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  		Table 1. Preoperative Patient Characteristics

 
Surgical approach and techniques
A median sternotomy with intrathoracic cannulation and aortic cross-clamping was used in the majority of patients. In reoperations, peripheral (femoral or axillary vessels) cannulation was not infrequently used. Four patients were placed on cardiopulmonary bypass, but the aorta was not cross-clamped and fibrillatory arrest was used because of severely calcified or porcelain type aorta. Off-pump CABG was performed in 1 patient, and hypothermic circulatory arrest was used in 3. Myocardial protection was performed using mild-moderate systemic hypothermia (median, 30°C; range, 15° to 34°C) with administration of cardioplegia antegrade only in 79 of 196 (40.3%) or both antegrade and retrograde in 110 (56.1%). Cold crystalloid cardioplegia solution was used in 106 of 196 (54%) patients earlier in the series, whereas cold (4°C) blood cardioplegia (4:1 ratio) was used in 85 of 196 (43.3%). Indication to perform coronary EA was made intraoperatively after arteriotomy revealed either an occluded lumen with no graftable vessel or if a 1-mm coronary probe could not be passed down the LAD. Patients in whom the LAD was found to be suitable for sequential internal mammary artery grafting proximal and distal to the lesion, or suitable for placing two separate grafts (eg, internal mammary artery and radial artery) proximal and distal to the lesion on the LAD, would not have been captured in our registry because they did not undergo LAD-EA.


   Results
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 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
The choice of technique of LAD-EA used in this report, either by small or long arteriotomy incision, was based on the surgeon preference. An open extended arteriotomy with vein patch angioplasty [7] was used in 54 of 196 (28%) of patients whereas a relatively short arteriotomy, with gentle traction and counter traction to remove the atheromatous plaque without disruption [8], was used in 142 of 196 (72%) of patients. Using this technique, an endarterectomy spatula was passed cephalad and caudad through the small arteriotomy to gently dissect the plaque from the media. Then the endarterectomy specimen was extracted in toto (Fig 1) with documentation of proper distal tapering. Otherwise the arteriotomy was extended to ensure complete vessel EA. With either technique, the proximal aspect of the plaque was divided sharply and allowed to retract cephalad. In the event proper distal tapering was not considered adequate, either with the small or large arteriotomy, the arteriotomy was extended distally as much as needed to ensure proper plaque tapering. Occasionally, the distal end of the plaque would need to be divided sharply, typically toward the distal LAD at the apex, and the intima secured to the media with interrupted 7-0 Prolene (Ethicon, Somerville, NJ) suture. In patients in whom a long arteriotomy was used, a vein patch was typically applied to the endarterecotomized bed, and the left internal mammary artery or vein graft was then applied to the hood of the vein patch.



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  		Fig 1. Endarterectomy specimen demonstrating proper tapering of distal branch vessels as well as proper tapering of a diagonal branch.

 
Whereas LAD-EA was performed in all patients, additional EA in the right coronary system was performed in 24 (12%) patients, in the left circumflex system in 3 (2%), and an additional 2 (1%) patients had EA in all three systems.

The number of CABG grafts performed was one in 4 of 196 patients (2%), two in 24 of 196 patients (12%), three in 93 of 196 patients (47%), four in 65 of 196 patients (33%), and five in 10 of 196 patients (5%) (Table 2) . The left internal mammary artery pedicled graft was anastomosed to the LAD in 151 of 196 patients (77%), and 54 of 196 (27.5%) required in addition a vein patch to close the extensive LAD endarterectomized bed. A saphenous vein graft was anatomized to the LAD in 45 (23%) patients because it was an urgent or emergent revascularization or it was in older patients. Concomitant procedures involved transmyocardial laser revascularization in 1 of 196 (0.5%), aortic valve replacement in 4 of 196 (2%), and mitral valve repair or replacement in 3 of 196 (1.5%).


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  		Table 2. Intraoperative Patient Characteristics

 
Operative morbidity and mortality
The overall operative mortality rate was 3% (6 of 196; Table 3) . Five of the deaths were as a result of cardiac causes and 1 was of multisystem organ failure. Perioperative MI in the LAD territory, defined as new electrocardiographic or echocardiographic changes with creatine kinase MB more than 100 mg/dL, occurred in 3% (6 of 196). Creatine kinase MB levels were documented in 161 of 196 (82%) patients, with a median value of 30 mg/dL (range, 5 to 407 mg/dL). The incidence of stroke was 6% (11 of 196). Sixteen patients (8%) required prolonged ventilatory support (>48 hours) owing to respiratory insufficiency, and 6 of 196 (3.2%) required reexploration for bleeding.


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  		Table 3. Postoperative Patient Characteristics, Morbidity and Mortality

 
Late morbidity and mortality
Late follow-up for mortality was 98% (186 of 190) and for morbidity, 74% (140 of 190). The discrepancy is explained by the use of the national social security database to detect whether patients who could not be otherwise contacted were still alive. Late survival was 94% (95% confidence interval [CI], 90% to 97%) at 12 months and 74% (95% CI, 66% to 80%) at 5 years (Fig 2). The majority of late deaths were cardiac in origin.



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  		Fig 2. Kaplan-Meier survival curve for 190 surviving patients. Five-year survival was 74%. (Pts = patients.)

 
Freedom from late cardiac events (angina, MI, congestive heart failure, PCI) that required hospital admission was 90% (95% CI, 84% to 94%) at 12 months and 84% (95% CI, 75% to 90%) at 5 years. Freedom from PCI to the LAD system was 99% (95% CI, 94% to 100%) at 12 months and 97% (95% CI, 92% to 99%) at 5 years. Among the 140 patients in whom late follow-up for nonfatal events was completed, 41 of 140 (29%) returned to the Brigham and Women's Hospital. Of these, 2 of 41 had developed recurrent angina, and 3 of 41 had developed recurrent MI in an endarterectomized territory: one in the right coronary territory, one in the left circumflex coronary territory, and one in the LAD territory. In one patient who underwent late catheterization the internal mammary artery graft and the LAD artery were widely patent (Fig 3).



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  		Fig 3. Late postoperative angiography demonstrating patent left internal mammary artery-to-left anterior descending coronary artery of an endarterectomized left anterior descending coronary artery.

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
The principal finding in this study is that patients with diffuse coronary artery disease may safely undergo LAD-EA as an adjunct to CABG with favorable long-term outcome.

Operative mortality and late survival
This study shows that LAD-EA can be performed with a low operative mortality rate (3%) and reasonable late survival (crude 5-year survival, 74%). This operative mortality rate is similar to the 2% to 6% reported in other institutions performing coronary EA [4, 9]. Our relatively low operative mortality rate reinforces the trend seen in recent studies on coronary EA [10, 11], as well as other areas of cardiac surgery, in which declining morbidity and mortality have been documented in several high-risk patient groups. The reasons are probably multifactorial. Advances in patient selection, surgical technique, myocardial protection, and intensive care unit management probably explain the improved operative mortality rates.

Our 5-year survival rate is in agreement with previous reports that have shown a survival rate between 71% and 92% [10, 12]. These results probably account for the presence of more-advanced coronary artery disease in patients who required LAD-EA compared with those who undergo conventional myocardial revascularization and the presence of more risk factors for worse early and late outcomes [3].

Perioperative myocardial infarction
Our MI rate (3%) is similar to conventional CABG (2.7% to 5%) [13, 14] and lower than previously reported for coronary EA (5% to 19%) [2, 12]. More-recent coronary EA studies have reported lower MI rates, similar to ours [10, 11], the discrepancy being primarily related to the definition of MI. We included patients with enzymatic definition of MI with concomitant electrocardiographic or echocardiographic changes in the LAD territory. Some reports [2, 10] have shown an increased risk in perioperative MI when an LAD-EA is performed, in contrast to when EA of the right coronary artery is performed [4, 9]. The increased risk in MI in the LAD territory seems to be correlated with the probability of blocking off small septal and diagonal branches when LAD-EA is performed [15]. In our experience, if the LAD-EA specimen is delivered intact (Fig 1), the likelihood of MI is low. In these patients, the alternative is incomplete revascularization, transmyocardial laser revascularization, or angiogenic growth factor therapy. We concur with previous reports that multiple EAs are a risk factor for early death as well as yielding poor long-term outcomes [9, 16].

Symptomatic relief
Symptomatic relief was accomplished in most patients. Freedom from cardiac events requiring hospital admission was 90% at 1 year and 84% at 5 years. Only 1 patient required reoperation CABG and only 6 needed PCI 5 years postoperatively, 4 to the LAD system. The rate of freedom from angina is lower than the 92% reported by Sergeant and associates [17] in a study of 9,600 patients undergoing coronary artery revascularization. It is, however, in agreement with previous reports on coronary EA. Asimakopoulos and associates [16] reported a 74.5% postoperative freedom from angina at 21 months' follow-up, whereas Djalilian and coworkers [10] reported a 91% freedom from angina at 3 years' follow-up. The differences in recurrence of angina between patients undergoing EA and those undergoing simple CABG may be related to the presence of severe diffuse coronary artery disease.

Indications and techniques for left anterior descending coronary endarterectomy
In this study, LAD-EA was performed only when conventional CABG was not possible. Our indications for LAD-EA were strict, and we only performed LAD-EA when arteriotomy revealed an occluded LAD with no graftable vessel or when a 1-mm probe could not be passed. Our low percentage of patients requiring LAD-EA (196 of 7,633, 2.6%) underscores our strict indications.

Among the two LAD-EA techniques, the long arteriotomy technique has the advantage of ensuring total plaque removal but typically requires a longer aortic cross-clamp time because of the need to sew the vein patch to the LAD-EA bed. The small arteriotomy technique has the advantage of a shorter cross-clamp time, but the surgeon must be assured that the entire plaque is removed with proper distal tapering. If distal tapering is not observed, then the arteriotomy should be extended to ensure complete plaque removal. In our series, we used the left internal mammary artery pedicle for the LAD anastomosis, either alone or in conjunction with a vein patch in the majority of patients, not only because of its documented superior patency [18], but also because the use of the left internal mammary artery for reconstruction of the LAD-EA has been shown to improve patency rate and 5-year survival when compared to the use of saphenous vein patch [19].

Anticoagulation and platelet inhibition
The anticoagulation protocol in our institution changed during the study period, with aspirin and clopidogrel, in combination, used more frequently since 1999. Before 1999, most coronary EA patients received at least 3 months of warfarin treatment together with a lifelong aspirin treatment. We still use heparin infusion at 500 U/h on the day of the surgery, and it is started only when the chest tube output is less than 50 mL for 2 consecutive hours. This strategy has not resulted in problems with postoperative bleeding, supported by the fact that only 3% of our patients required a return to the operating room for bleeding.

Studies on anticoagulation protocols after coronary EA are not available. Our choice of postoperative aspirin and clopidogrel has partially been based on studies on thrombosis after PCI [20]. Several studies have documented that more than aspirin alone is required to maintain long-term patency in culprit vessels in the setting of disturbed coronary endothelium [3].

Limitations
A limitation of this study is its retrospective design, with data captured over time and reliance on patients for reporting late events. Accordingly, our late follow-up for nonfatal events was only 78%. Our 100% follow-up for late mortality, on the other hand, can be regarded as very reliable. A lack of a control group is also a limitation, but such a study is not practical because conventional CABG was, by definition, not possible in these patients. Another limitation is the lack of late angiographic follow-up to evaluate graft patency. Recatheterization after CABG, with or without coronary EA, is not routine at any institution. The few symptomatic patients who underwent recatheterization in our study do not provide reliable information about graft patency. Previous studies have shown 38% to 100% long-term angiographic graft patency after coronary EA, and this wide difference was related to different timing for postoperative angiography and different patient populations [3, 12]. In a study that included late angiography, Ferraris and colleagues [3] showed that in patients who underwent coronary EA, at a mean of 7.1 years after operation, late patency in endarterectomized vessels was worse than nonendarterectomized vessels (40% versus 58%). This was in contrast to 65% patency in a control group who underwent conventional CABG only. We believe that late graft patency will be impossible to document for reasons mentioned above. Furthermore, unless patency can be correlated with long-term survival in coronary EA patients, as in conventional CABG patients [18], the only practical outcome that matters or that can be documented is late cardiac-related death or late nonfatal cardiac events. We have shown favorable outcomes in these measurements.

Implications
The results of this study are important because many patients with diffuse LAD disease are currently considered inoperable. This is in contrast to patients in whom the LAD is deemed graftable by angiography but not other targets and the referring physicians and surgeons may wish to undertake CABG because of the presence of a graftable LAD. In some patients, transmyocardial laser revascularization may be considered as an option, but there are still many unanswered questions regarding the indications and long-term results of this treatment. Transmyocardial laser revascularization should be considered complementary to coronary EA and remain in the armamentarium of surgeons treating diffuse coronary disease. Angiogenic growth factor therapy is also promising, but it is still experimental.


   References
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 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Bailey C, May A, Lemmon W. Survival after coronary endarterectomy in man. JAMA. 1957;164:461–466
  2. Livesay JJ, Cooley DA, Hallman GL, et al. Early and late results of coronary endarterectomy. Analysis of 3,369 patients. J Thorac Cardiovasc Surg. 1986;92:649–660[Abstract]
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  6. Sellke FW, Laham RJ, Edelman ER, Pearlman JD, Simons M. Therapeutic angiogenesis with basic fibroblast growth factor: technique and early results. Ann Thorac Surg. 1998;65:1540–1544[Abstract/Free Full Text]
  7. Gill IS, Beanlands DS, Boyd WD, Finlay S, Keon WJ. Left anterior descending endarterectomy and internal thoracic artery bypass for diffuse coronary disease. Ann Thorac Surg. 1998;65:659–662[Abstract/Free Full Text]
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  11. Shapira OM, Akopian G, Hussain A, et al. Improved clinical outcomes in patients undergoing coronary artery bypass grafting with coronary endarterectomy. Ann Thorac Surg. 1999;68:2273–2278[Abstract/Free Full Text]
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