CABG With a Long LAD Endarterectomy

In this video, Dr. Vince Gaudiani demonstrates the practice of a long LAD endarterectomy. He also showed his technique for removing all the valves from the vein and removing any areas in the vein that did not look good. 

He first performed a normal distal RCA anastomosis to demonstrate a normal distal anastomosis.  An OM graft was also done, though it was not shown.   

He then performed a LAD endarterectomy along the entire length of the LAD, removing all the calcium from the LAD and a diagonal branch.   

He then placed a large vein patch over the top and completed the operation with a LIMA to the vein patch on the LAD.  

Author’s Note 

A previously published video by Dr. Thais Faggion Vinholo and colleagues demonstrates a new use for an older technique. Long segment open LAD endarterectomy, developed by Dudley Johnson 40 years ago, still plays a minor but important role in coronary bypass surgery. I made this video of the technique presented here for comparison of the two techniques. I have tried several times to endarterectomize long segments of LAD stents and failed because the healing process of the stents in the LAD had obliterated the septal perforators. At least that is what I thought at the time, but if you listen carefully to the technique presented by Vinholo et. al., it is apparent that they made several very intelligent anticoagulation maneuvers at the end of their operation that led to its success. Please note, filling the LAD with stents is extremely unwise. The vessel is a soaker hose, not a conduit. 

In general, long segment open LAD endarterectomy for coronary disease works best when the original LAD is large, when the anteroseptal wall still has good contractility, and when the Mills endarterectomy set developed by Noel Mills is accessible. I hope Dr. Vinholo and her team get a follow-up angiogram on their patient. I believe we can improve the results of routine long segment endarterectomy by adopting their anticoagulation strategy. 

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