Multiple coronary endarterectomy in diffuse complex coronary artery disease

A 53-year-old male, known patient of hypertension, hyperlipidemia and type I diabetes mellitus, presented to the hospital with acute-onset chest pain. After initial evaluation, he was diagnosed to have non-ST elevation myocardial infarction. Coronary angiogram showed severe triple vessel disease with chronic total occlusion of left anterior descending artery and significant diffuse lesions in the left circumflex artery and right coronary . He was referred for coronary artery bypass grafting.

Surgical Procedure

After initial evaluation, the patient underwent coronary artery bypass grafting on cardiopulmonary bypass. Diffuse disease of the left anterior descending artery (LAD) with lumen of less than 1mm necessitated long closed manual endarterectomy of proximal, mid and distal LAD. Left internal mammary artery was anastomosed to the distal LAD. Diffuse calcific disease with very narrow lumen of obtuse marginal branch of left circumflex was found. This required another closed manual endarterectomy of the same vessel followed by vein graft to it. Additional three vein grafts were placed to the posterior descending artery, posterolateral branch and diagonal branch after endarterectomy of those vessels. Electively this patient was put on intra-aortic balloon pump for 24 hours. Patient had an uneventful post-operative recovery with no ischemic events or hemodynamic instability. Post-operatively patient was discharged on the 6th post-operative day on antiplatelet and anti-coagulants in addition to routine postoperative medications.

Discussion

Diffuse coronary artery disease (CAD) as such cannot be tackled with percutaneous coronary intervention and is more likely to be referred for CABG. However, up to 25% of patients with diffuse CAD cannot be safely and successfully treated by standard CABG. Therefore, several techniques including coronary endarterectomy, which involves the removal of the atherosclerotic core from the coronary artery lumen through an arteriotomy, have evolved over the years. Despite initial adverse results (high operative mortality and perioperative myocardial infarction), several recent publications have shown that it can be safely performed with improvement in surgical technique and immediate post-operative anti-thrombotic measures. Coronary endarterectomy can assure complete revascularization preventing residual ischemia. We have described a patient in whom we did multiple endarterectomies successfully.

Diffuse coronary artery disease options