Asian Cardiovasc Thorac Ann 2006;14:227-230
© 2006 Asia Publishing EXchange Ltd
Off-Pump Coronary Endarterectomy in High-Risk Patients
Feza Nurozler, MD,
Tolga Kutlu, MD,
Güngör Küçük, MD,
Candan Ökten, MD
Division of Cardiovascular Surgery, Central Hospital, Izmir, Turkey
For reprint information contact: Feza Nurozler, MD Tel: 90 533 332 3088 Fax: 90 232 345 3456 Email: fnurozler{at}yahoo.com, Central Hospital 1644 sok 2/2, Bayrakli, Izmir, Turkey.
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ABSTRACT
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The outcome of off-pump endarterectomy in patients with diffuse coronary artery disease and increased risk factors for cardiopulmonary bypass was reviewed. Thirty-eight procedures were carried out in 32 patients (21 men and 11 women) aged 59 to 78 years (mean, 69 years). Mean left ventricular ejection fraction was 38.6% (range, 24% – 55%). The number of grafts per patient was 2.6. The left internal mammary artery was used in 29 patients (91%). Endarterectomy was performed on the right coronary artery and its branches (18), the left anterior descending artery (15), diagonal branch (2), and the circumflex system (3). Overall operative mortality was 3.1%. Perioperative myocardial infarction occurred in 6.2%. Follow-up was complete in 30 patients (94%). The mean follow-up period was 14 ± 3.3 months. Late survival was 93%. Freedom from cardiac events that required hospital re-admission was 89%. Freedom from angioplasty of the endarterectomized vessel was 96%. These findings indicate that off-pump endarterectomy can be performed with good results in patients with diffuse coronary artery disease.
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INTRODUCTION
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Coronary endarterectomy without associated coronary artery bypass grafting (CABG) was introduced to treat coronary artery disease and was performed initially without cardiopulmonary bypass (CPB).1 Currently, endarterectomy has a role as an adjunct to CABG, mainly in patients with diffuse coronary disease, to achieve more complete revascularization. Recent advances in percutaneous coronary interventions have resulted in more patients with advanced age and diffuse coronary disease being referred for CABG.2 Due to increasing age, preoperative renal, pulmonary, and neurological problems are encountered more often. Off-pump CABG has many advantages in high-risk patients.3 However, endarterectomy is often necessary in those with diffuse disease. Concerns about technical difficulties and adequacy of endarterectomy expose patients to the risks of CPB. In this study, the early results of off-pump endarterectomy in patients with increased risk factors for complications after CPB were analyzed.
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PATIENTS AND METHODS
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Of the 238 patients who underwent off-pump CABG by the same surgeon between October 2002 and October 2004, 32 (13.4%) had a total of 38 coronary endarterectomies. The main reasons for choosing an off-pump procedure were the factors shown in Table 1
. Ages ranged from 59 to 78 years, and left ventricular ejection fractions ranged from 24% to 55%. Preoperative renal failure was defined as a serum creatinine level > 2.0 mg·dL–1. Postoperative renal failure was defined as urine output < 500 mL per day and creatinine level > 2.5 mg·dL–1. One patient was on hemodialysis preoperatively. Severe pulmonary disease was defined as forced expiratory volume in 1 second < 50% of predicted and a resting arterial PCO2 > 50 mm Hg or arterial PO2 in room air < 70 mm Hg. Heart failure was defined as New York Heart Association functional class III or IV. Perioperative myocardial infarction (MI) was established by new electrocardiographic or echocardiographic changes with creatine kinase MB (CK-MB) more than 100 mg·dL–1 and/or CK-MB/total CK ratio > 10%. CK-MB and total CK levels were assessed within 12 hours after surgery. Prolonged ventilatory support was > 48 hours. Preoperatively, intra-aortic balloon pumping was not used in any patient. Late follow-up was completed by telephone contact with either the patient or their referring cardiologist.
Complete revascularization was aimed for in all patients. All operations were carried out through a full sternotomy. The left internal mammary artery (LIMA) was prepared in all cases except the 2 re-operations. Anticoagulation was achieved with heparin (150 U·kg–1). The decision to perform coronary endarterectomy was made preoperatively or when arteriotomy revealed an occluded lumen unsuitable for grafting or if a 1 mm coronary probe could not be passed down the target vessel (Figure 1). An open extended arteriotomy with vein patch angioplasty was used in 14 (36%) procedures: 10 on the left anterior descending artery (LAD), 3 on the right coronary (RCA), and 1 on the circumflex (CX). A relatively short arteriotomy with gentle traction and countertraction to remove the atheromatous plaque without disruption was used in 24 (63%) procedures (5 LAD, 15 RCA, 2 diagonal, and 2 CX).4,5 When a long arteriotomy and a LIMA graft were used, a vein patch was typically applied to the endarterectomized bed, and the LIMA was then applied to the hood of the vein patch.
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Figure 1. Preoperative angiogram of a patient who required endarterectomy to the left anterior descending coronary artery.
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With a saphenous vein graft, the appropriate length was opened and applied directly to the endarterectomized bed. The endarterectomy specimen was extracted. Adequate endarterectomy was accepted when distal tapering was documented. If distal tapering was considered inadequate, the arteriotomy was extended to ensure proper plaque tapering. With either technique, the proximal plaque was pulled out and cut to retract it proximally. No stabilizer was used for treating the LAD, RCA, diagonal, and posterior descending artery (PDA) branches. Exposure of the LAD and diagonal branch was achieved by placing a sponge under the heart and using a deep pericardial traction stitch to elevate and slightly rotate the heart rightward. Exposure of the RCA and PDA branches was obtained by rotating the heart leftward using rightward traction with an unfolded gauze placed at the base of the heart. Stabilization of the heart was accomplished using 2 stay sutures (3/0 braided coated polyester) placed proximal and distal to the area planned for arteriotomy. To expose the CX and posterolateral branch of the RCA, 2 deep pericardial traction stitches were placed near the left upper pulmonary veins and to the left of the inferior vena cava, thereby achieving vertical displacement of the apex. To obtain further exposure of the target arteries on the lateral and inferior aspect of the heart, the patients were also slightly rotated to a right decubitus Trendelenburg position. The right pleura was opened widely, and the right side of the sternum was lifted up by placing a rolled compress under the right arm of the sternal retractor. The heart was lifted up, rotated rightward, and placed in the right hemithorax. Gauze was placed between the heart and the right side of the sternum. An Octopus I stabilizer (Medtronic Inc., Minneapolis, MN, USA) was occasionally applied to the CX and posterolateral branch of the RCA when proximal sections were chosen for anastomosis. Two stay sutures (3/0 braided coated polyester) were placed proximal and distal to the area planned for arteriotomy. The inferior vena cava was freed from the pericardium and diaphragm as much as possible to prevent kinking of the vena cava so that the heart could tolerate vertical displacement. Proximal anastomosis was performed during aortic occlusion with a side-biting clamp. All patients received warfarin in addition to aspirin for 3 months postoperatively.
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RESULTS
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The operative details are given in Table 2. Left internal mammary artery anastomosis over a saphenous vein patch was performed in 8 patients having endarterectomy to the LAD when the LIMA was not long enough to cover the arteriotomy. LIMA anastomosis was carried out to the diagonal branch in 3 patients, to the CX in 1, and to the LAD in the others. Endarterectomy was undertaken on the RCA and its branches in 18 patients, the LAD in 15, the diagonal branch in 2, and the CX in 3. Three patients were converted to conventional coronary endarterectomy because of hemodynamic deterioration. One of them died due to multi-organ failure. This was the only hospital mortality (Table 3); the patient had been on hemodialysis preoperatively. Four patients (12.5%) required prolonged ventilatory support owing to respiratory insufficiency, stroke, and renal failure. Mid-term follow-up was complete in 30 patients (93%). The mean follow-up period was 14 ± 3.3 months. Two patients died in the late period; late survival was 93%. One of the deaths was cardiac in origin, the other was caused by a perforating peptic ulcer.
Freedom from cardiac events requiring hospital re-admission was 89%. Freedom from angioplasty to the endarterectomized vessel was 96%. Of the 30 patients followed up, 18 (60%) returned: 3 had developed recurrence of angina, and 1 had MI in the endarterectomized RCA territory. In 3 patients who underwent late coronary angiography, the endarterectomized vessels were found to be widely patent (two LIMA to LAD, one vein graft to PDA).
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DISCUSSION
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Many surgeons have adopted complete revascularization of all occluded or significantly stenosed coronary arteries that supply viable myocardium without residual distal disease.3 In patients with diffusely diseased coronary arteries, complete revascularization can be achieved only by performing an endarterectomy, as introduced by Bailey and colleagues1 who initially performed it without CPB or without associated CABG. Currently, endarterectomy has a role as an adjunct to CABG, mainly in diffuse disease, to achieve more complete revascularization. Some surgeons are still reluctant to use endarterectomy because of the increased rates of mortality and MI compared with CABG alone.6–8 However, with advances in intraoperative management and postoperative care, there is a trend toward lower MI and mortality rates in recent studies.9,10 As patients needing endarterectomy are older with potentially more risk factors, part of the mortality and morbidity is due to non-cardiac complications.2,7–10 The relationship between non-cardiac complications and prolonged CPB and ischemic times is well documented.11 Recent studies suggest that overall operative mortality and hospital complications are lower in off-pump operations in high-risk groups.3,12 Off-pump coronary endarterectomy as an adjunct to CABG has been found to have acceptable results in high-risk patients with diffusely diseased coronary arteries.13,14 A comparison of off-pump and conventional coronary endarterectomy showed reduced mortality, morbidity, intensive care unit and hospital stay in the off-pump group.14
We were unable to compare the results of off-pump and conventional coronary endarterectomy because the conventional procedure was preferred in patients without additional risk factors. However, our operative mortality (3.1%) is similar to rates reported from institutions performing conventional coronary endarterectomy (2% – 3%).2,9,10 Our relatively low operative mortality in high-risk patients reinforces the importance of avoiding CPB. The endarterectomy technique is also important. Ensuring proper distal plaque tapering is crucial to prevent occlusion due to dissection or atheromatous embolization. The arteriotomy should be extended distally as much as needed to ensure proper plaque tapering. Avoidance of a stabilizer allows extension of the arteriotomy when needed. We only used a stabilizer for the proximal part of the CX and posterolateral branch of the RCA.
Our MI rate (6.2%) was similar to that reported for conventional endarterectomy (5% – 19%).8,9,15 In previous series, increased risk of perioperative MI was noted in the LAD territory rather than the RCA.6–8 This might be due to blocking of small septal and diagonal branches during LAD endarterectomy. In contrast, both perioperative MIs in this series occurred in the RCA territory; use of an open extended arteriotomy technique in most LAD endarterectomies (10/14) may explain this. Another limitation of this study is its retrospective design; however, a prospective randomized study was not possible as patient characteristics would be quite different since off-pump coronary endarterectomy is preferred in high-risk patients. Furthermore, there is a lack of late angiographic follow-up to evaluate graft patency. Repeat catheterization of the few symptomatic patients did not provide reliable information about graft patency.
Most patients enjoyed symptomatic relief. Freedom from cardiac events requiring hospital re-admission was comparable with series of conventional coronary endarterectomy.2,9,10 Only one patient developed MI in the endarterectomized territory, and required angioplasty. However, the follow-up period in our study was shorter than previous series. Nevertheless, it was concluded that off-pump coronary endarterectomy can be performed with good results in patients with diffuse coronary artery disease and increased risk factors for CPB, but long-term follow-up is required to support this finding.
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REFERENCES
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- Bailey C, May A, Lemmon W. Survival after coronary endarterectomy in man. JAMA 1957;164:461–6.[Abstract/Free Full Text]
- Byrne JG, Karavas AN, Gudbjartson T, Leacche M, Rawn JD, Couper GS, et al. Left anterior descending coronary endarterectomy: early and late results in 196 consecutive patients. Ann Thorac Surg 2004;78:867–74.[Abstract/Free Full Text]
- Akiyama K, Ogasawara K, Inoue T, Shindou S, Okumura H, Negishi N, Sezai Y. Myocardial revascularization without cardiopulmonary bypass in patients with operative risk factors. Ann Thorac Cardiovasc Surg 1999;5:31–5.[Medline]
- 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;65:659–62.[Abstract/Free Full Text]
- Aranki SF. A modified reconstruction technique after extended anterior descending artery endarterectomy. J Card Surg 1993;8:476–82.[Medline]
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- Livesay JJ, Cooley DA, Hallman GL, Reul GJ, Ott DA, Duncan JM, et al. Early and late results of coronary endarterectomy. Analysis of 3,369 patients. J Thorac Cardiovasc Surg 1986;92:649–60.[Abstract]
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- Arom KV, Flavin TF, Emery RW, Kshettry VR, Petersen RJ, Janey PA. Is low ejection fraction safe for off-pump coronary bypass operation? Ann Thorac Surg 2000;70:1021–5.[Abstract/Free Full Text]
- Eryilmaz S, Inan MB, Eren NT, Yazicioglu L, Corapcioglu T, Akalin H. Coronary endarterectomy with off-pump coronary artery bypass surgery. Ann Thorac Surg 2003;75:865–9.[Abstract/Free Full Text]
- Naseri E, Sevinc M, Erk MK. Comparison of off-pump and conventional coronary endarterectomy. Heart Surg Forum 2003;6:216–9.[Medline]
- Asimakopoulos G, Taylor KM, Ratnatunga CP. Outcome of coronary endarterectomy: a case-control study. Ann Thorac Surg 1999;67:989–93.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
