Long-term results of reconstructions of the left anterior descending coronary artery in diffuse atherosclerotic lesions

Abstract

Extended revascularizations of the left anterior descending coronary artery increase surgical risk, although not to a statistically significant degree, and should be performed only of necessity. However, once needed, revascularization is a lifesaving procedure with acceptable early and long-term results.

Patch Angioplasty in Diffusely Diseased Left Anterior Descending Coronary Artery

“…The reported surgical risk of a combined endarterectomy with patch angioplasty was controversial. Tasdemir et al [11] reported non-significant lower rates of MI and mortality, while Fukui et al [1] have demonstrated a statistically significant higher rate of perioperative MI in this subgroup of patients, compared to those benefiting from angioplasty alone.…”

“…We are still reluctant to combine endarterectomy to our technique, even if the early as well as the late results of more recent series have been acceptable and that the whole procedure can be safely performed off-pump [1,11,13,14]. We still believe that in part, endarterectomy will add complexity to surgery for the need of a longer arteriotomy, more operative time, more blood loss and increased hospital mortality.…”

“…Among this population are patients with diffuse coronary disease who were before deemed inoperable and managed medically, with substantial number having persistent symptoms and restricted physical activity [4]. With a diffusely diseased LAD that is frequently encountered in this patient population, complete myocardial revascularization is hardly achieved by conventional bypass techniques [6,8] and the long-term patency of a LIMA to LAD graft is usually jeopardized by the multiple atheromatous plaques [9] several technical variations and surgical combinations have been suggested to reconstruct the diffusely diseased LAD that included: jumping anastomosis and creation of more than one bypass to the LAD territory, endarterectomy, venous patch angioplasty followed by LIMA anastomosed on the patch [10] and extended LIMA patch angioplasty, with or without endarterectomy [1,4,6,[11][12][13].…”

“…The technique and extent of endarterectomy are also subjects of debate. For some, endarterectomy should be limited [6,12] others advocate for more liberal use with total removal of the plaque under direct vision [1,7,11].…”

“…There is a general agreement that extended LAD revascularization carries a surgical risk and should be only performed when necessary [11]. Tasdemir et al [11] have shown that the procedure was associated with 4 folds hospital mortality and 5-6 folds of inhospital MI, compared to conventional CABG. The reported hospital mortality varied between <1% -6.5% [12].…”