Outcome and graft patency in coronary artery bypass grafting with coronary endarterectomy

Abstract

Background: Controversy persists regarding the use of coronary endarterectomy (CE) in patients with severe coronary artery disease. We compared the comorbidities and perioperative characteristics of patients undergoing coronary artery bypass grafting (CABG) with and without CE.

Methods: This study was performed in two private hospitals in Shiraz, Iran from May 2010 to December 2011 on 967 patients who underwent CABG without CE and 84 patients who underwent CABG with CE (the CE+ group). After follow-up at 9.66±3.65 months post-surgery, 28 patients from the CE+ group underwent angiography to evaluate the patency of grafts and native coronary vessels.

Results: Patients in the CE+ group had a more prevalent history of diabetes (48% vs. 36%) and number of diseased vessels (2.88±0.39 vs. 2.70±0.85). The overall hospital mortality was 1.8%, and no significant difference was observed between the two groups. In the 28 patients who underwent reangiography, 113 vessels were bypassed and 29 endarterectomies were performed, mostly on the left anterior descending artery (12 endarterectomies) and the right coronary artery (8 endarterectomies). In the endarterectomized vessels, a 66% patency rate was found in both the grafts and the native vessels. The native coronary vessels were more likely to be patent when the left internal mammary artery was used as a conduit than when a saphenous vein bypass graft was used.

Conclusion: The lack of a significant difference in postoperative complications in patients who underwent CABG with or without CE may indicate that CE does not expose patients to a higher risk of complications. Since most of the endarterectomized vessels were shown to be patent during the follow-up period, we propose that endarterectomy is a viable option for patients with severely diseased vessels.

Keywords: Comorbidity; Coronary artery bypass surgery; Coronary endarterectomy.

Fig. 1

Kaplan-Meier survival curve of patients who underwent coronary artery bypass grafting with coronary endarterectomy, showing a survival rate of nearly 80% after 20 months of follow-up.

Fig. 2

Kaplan-Meier curve of (A) graft patency and (B) patency of the grafted coronary vessels for patients who underwent angiography at a follow-up visit, showing relatively better patency in grafts compared to grafted coronary vessels, although no statistical analysis was performed.

Fig. 3

Kaplan-Meier curve of (A) graft patency and (B) patency of the grafted coronary vessels for the 28 patients who underwent angiography at a follow-up visit for grafts with and without endarterectomy. Log-rank analysis shows that the patency of endarterectomized vessels was significantly lower than that of non-endarterectomized vessels. Graft patency also tended to be higher in the absence of endarterectomy.

Fig. 4

Kaplan-Meier curve of (A) graft patency and (B) patency of the grafted native coronary vessels for patients who underwent angiography at a follow-up visit, based on the type of graft conduit. The type of conduit (the LIMA vs. SVG) did not affect graft patency, but the patency of native vessels was greater when the LIMA was used as a conduit than when the SVG was used. LIMA, left internal mammary artery; SVG, saphenous vein graft.

Fig. 5

Kaplan-Meier curve of (A) graft patency and (B) the patency of the grafted coronary vessels for patients who underwent angiography at a follow-up visit, based on the type of the grafted coronary vessel. Log-rank analysis shows that neither graft patency nor the patency of the grafted coronary vessel was affected by the type of the grafted coronary vessel. LAD, left anterior descending artery; RCA, right coronary artery; PDA, posterior descending artery; PLVB, posterolateral ventricular branch; CM, circumflex marginal.

Fig. 6

Kaplan-Meier curve of (A) graft patency and (B) the patency of the grafted coronary vessels for patients who underwent angiography at a follow-up visit, based on the side of the grafted coronary artery. Operations on the LAD were compared to operations done on the RCA, the branches of the PDA, or the PLVB. Log-rank analysis showed no difference in graft patency and the patency of native coronary vessels. LAD, left anterior descending artery; RCA, right coronary artery; PDA, posterior descending artery; PLVB, posterolateral ventricular branch.

Fig. 7

Kaplan-Meier curve of (A) graft patency and (B) the patency of the grafted coronary vessels for endarterectomized vessels that underwent angiography at a follow-up visit, separated into grafts on the LAD and grafts on other vessels. Log-rank analysis showed no difference in graft patency or the patency of native coronary vessels. LAD, left anterior descending artery.

Fig. 8

Kaplan-Meier curve of (A) graft patency and (B) the patency of the grafted coronary vessels for endarterectomized vessels that underwent angiography at a follow-up visit, separated into grafts on the RCA, the PDA, or the PLVB, and grafts on other vessels. Log-rank analysis showed no difference in graft patency or the patency of native coronary vessels. RCA, right coronary artery; PDA, posterior descending artery; PLVB, posterolateral ventricular branch.