Coronary Endarterectomy of the Left Anterior Descending Artery

Kelly Wanamaker

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Coronary Endarterectomy of the Left Anterior Descending Artery

Thursday, January 5, 2017

By

Kelly Wanamaker

In experienced hands, coronary endarterectomy (EA) has been performed with good results. The procedure can facilitate conversion of severe ungraftable disease to a graftable coronary artery, and provide outcomes comparable to CABG. Many surgeons are still reluctant to use coronary EA primarily because of increased mortality and myocardial infarction rate postoperatively compared with CABG alone.

The authors present the case of a 64-year-old man with hypertension, diabetes, and a non-ST elevation myocardial infarction. Cardiac catheterization showed severe 3-vessel coronary artery disease with depressed left ventricular function. Given the extent of the patient’s diffuse coronary disease, surgical intervention was denied at an outside facility and he was managed medically. Due to persistent ongoing angina, the patient was referred to Brigham and Women’s Hospital two months later. The patient subsequently underwent a LAD coronary endarterectomy with CABG x 3. At a 4-month follow up visit, the patient was doing well.

This video demonstrates a long segment left anterior descending coronary endarterectomy with saphenous vein angioplasty and LIMA-LAD. The postoperative anticoagulation protocol from Brigham and Women’s Hospital is also described.

This video is also authored by Luigino Nascimben.

Comments

Submitted by David Carlson on Sun, 2017-01-08 12:00

I enjoyed the video presentation and certainly agree that this technique is useful. I commonly apply endarterectomy to the RCA bifurcation when diseased and the distal branches are small, but have not done many to the LAD. This technique is likely to be more needed in the future as we see our population changing to more diabetic patients with diffuse disease and previous multi vessel stunting.

Submitted by Mohammad Samir Sunny on Mon, 2017-01-09 22:41

In BSMMU, Dhaka we performed more than 100 cases of LAD endarterectomy where there was no alternative and we found good result.

Submitted by Younes Moutakiallah on Tue, 2017-01-10 17:59

Good technique, but about antithrombotic therapy?

Submitted by Ahmed El-Eshmawi on Tue, 2017-01-10 18:18

Great presentation, however I would not underestimate the importance of doing a full Maze in addition to the triple vessel bypass giving his age and LV systolic dysfunction, however this is another discussion. Well done.

Submitted by Axel Tolstano on Tue, 2017-01-10 19:52

In CGN , we perform lad endarterectomy with very good results . We use only aspirin in postop . Never plavix

Submitted by Aristotle Protopapas on Wed, 2017-01-11 03:51

Coronary Endarterectomy preceded Favaloro and the Leningrad pioneers, and there is good reason it has not been popularised. Only a post-operative contrast study could evaluate this brave revascularisation attempt on this diabetic patient! We should be always mindful of vascular biology and pathology, although the interventionalists seem occasionally oblivious to Virchow....

Submitted by Sarkis Ejbeh on Thu, 2017-01-12 23:49

For localised atherocalcifications i do short on site endarterectomy.. If diffuse ones i prefer an open endarterectomy along the artery avoiding the risk of branches avulsion..using a saphenous patch angioplasty to roof the opening arteriotomy..following by arterial or SVG bypass..

Submitted by Adem Diken on Sat, 2017-01-14 02:03

Very good presentation, thank you. I perform coronary EA which is life saving when it's mandatory to perform in diffusely diseased arteries without a suitable anastomosis site. Stabilizing proximal and distal plaque is crucial in open technique

Submitted by Oleksandr Babliak on Sat, 2017-01-14 03:28

Sequential LIMA grafting in that case would be effective and less invasive.

Submitted by Kelly Wanamaker on Sat, 2017-01-14 21:39

In response to : Younes Moutakiallah on Tue, 2017-01-10 17:59 Our anticoagulation protocol is described in the video: aspirin and plavix (plavix load followed by 75mg daily; a heparin drip is started on the day of surgery if chest tube output is less than 50mL for 2 consecutive hours; it is not titrated). Thank you for your interest. We appreciate comments and feedback.

Submitted by Patrick Myers on Fri, 2017-01-20 09:56

Very nice video. We reported the long-term results of this technique in 224 patients: https://www.ncbi.nlm.nih.gov/pubmed/22502972

Submitted by Christophoros Kotoulas on Tue, 2017-02-28 12:43

i enjoyed the video. I agree with the way to do it. i prefer salospir 100mg tb od and sintrom with a target INR 2-3 for 6 months and after it salospir 100mg tb od and plavix 75mg tb od.

Submitted by Rahul Rao on Sun, 2020-03-15 08:32

Thank you for a really good teaching video... the procedure and the specimen did not show septal branches of the lad.... how important is it in your opinion to get the endarterectomy specimen out along with the septal perforators

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