Coronary Artery Endarterectomy in Chinese Patients – Harvesting a Complete Plaque: A Case Report

Case Report

Coronary Artery Endarterectomy in Chinese Patients – Harvesting a Complete Plaque: A Case Report

Corresponding author: Shanmukha Sasank Boggavarapu, Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, No: 1 Jian Sha East road Zhengzhou, Henan, PR China – 450000; Email: 991812866@qq.com

Abstract

In 1957 Bailey and associates introduced endarterectomy of the coronary arteries. Since then endarterectomy had been a tradition in a complex diffused coronary artery disease. With skillful hands, coronary artery endarterectomy will be safer and successful along with following a good anti-coagulant therapy gives long-term patency benefits.

Case presentation:

A 56-years-old male with hypertension, atrial fibrillation and type-II diabetes presented with a non-ST-elevation and myocardial infarction 6weeks prior surgery. CT-angiogram shows multiple vessel diseases. Coronary angiogram revealed 100% proximal right coronary artery (RCA) stenosis, 70% proximal circumflex and 80% obtuse marginal stenosis and diffusely diseased left anterior descending artery (LAD) with 80% mid and 70% distal stenosis. Echocardiogram show moderately declined left ventricular function with no valvular lesions. Because of extensive coronary artery disease, surgeons denied coronary artery stenting. Most adequate treatment for his condition was coronary artery bypass graft (CABG) with coronary endarterectomy.

Surgical technique 

The operation was carried out through a standard median sternotomy and harvesting left internal mammary artery (LIMA) and the great saphenous vein in an old fashion and then carried out with a standard cardiopulmonary bypass (CPB) with aortic cannulation and two-stage single venous right atrial cannulation. As LAD and first diagonal (D1) are heavily calcified with a hard and soft plaque. This patient went on LAD coronary endarterectomy. The technique demonstrated here is that endarterectomy is performed through small and proximal coronary arterectomy. The LAD was diffusely diseased and extending toward the apex of the heart and requires an extensive endarterectomy. Although it’s not possible to remove without any breakage of the plaque there is a second distal arterectomy was performed for completion. An endarterectomy stachler is passed through cephalad and caudad through the small arterectomy in order to free the plaque from the media. The distal endarterectomy is performed with careful and meticulous traction and counter traction to remove the plaque without any destruction. A 1mm probe is used to further free the plaque from adhesions and then further traction and counter-traction is used to free the specimen. Still, it’s been a difficult task to remove the complete plaque. Then the proximal arterectomy is extended toward the distal arterectomy and then the endarterectomy specimen is extracted in total. Retrograde cardioplegia is given to flush the all debris within the lumen. Then the complete arterectomy is sewing together with the vein patch using continuous 8-0 polypropylene sutures and LIMA was applied to the proximal of LAD with an end to side fashion using continuous 7-0 polypropylene sutures. The circumflex and obtuse marginal endarterectomy was performed with a single arterectomy and sewing the artery together with a venous patch to widen the lumen. RCA and circumflex artery were applied with individual vein grafts with an end to side fashion. The total cross clam time is 110 minutes and CPB time is around 128 minutes. The patient was then transferred to intensive care unit (ICU) and extubated 6 hours after surgery. The anticoagulation protocol in our hospital includes aspirin and clopidogrel. We give a 200 mg aspirin on the night of surgery and we start heparin of 500 U/hour when the chest tube drain is ≤ 50 ml/hour for 2 hours and continue for 48 hours. We then give a clopidogrel in 4 divided doses of 75 mg for four hours. This protocol gives good results in post CABG patients. The next day patient was transferred to the step-down unit and treated for persistent chronic atrial fibrillation. Since his diabetes did not affect his recovery the patient was discharged on a postoperative day 10 following his drug dose 200 mg aspirin and 75 mg clopidogrel. Follow-up after 6 months, the bypass grafts both native artery and conduits were patent with improved left ventricular function.

Figure 1: Coronary artery angiogram viewing left anterior descending branch (LAD) and diagonal branch (D1).

Figure 2: Coronary artery endarterectomy harvesting the complete plaque from LAD.

Figure 3:  Sewing the coronary artery with a vein patch and left internal mammary artery anastomosis done over the vein patch.

Figure 4: Harvested specimen is a 7cm plaque from LAD along with a 3cm plaque from a diagonal branch.

Patients and results

In the past 5years CABG is performed over 3218 patients with coronary heart disease in our institute. Among the 76 patients (2.3%) coronary arteries were restored with endarterectomy and vein patch reconstructive technique. There were 29 female and 47 male patients with an average age of 53 years. Preoperative left ventricular ejection fraction (LVEF) ranges from 44%-65%. The average coronary artery endarterectomy ranges from 1 cm to7 cm and in 13 patients arterectomy was extended into a diagonal branch was performed. In these 13 patients, a ‘Y’-shape vein patch is used for reconstruction. If arterectomy is very long then a separate vein patch is used to reconstruct the diagonal branch. In 21 patients LIMA anastomosis is done on a vein patch. All these 76 patients that went on endarterectomy and vein patch reconstruction the CABG is performed with individual grafts. There is no postoperative death recorded. All these 76 patients have followed up an average of 3 months to 36 months. 2 patients returned in less than a year with episodes of angina. Coronary artery angiogram shows good patency of the endarterectomy vessel and the block of other arteries is the cause of angina. They were discharged after interventional treatment. Following the good lifestyle and strict anti-coagulant protocol gives a long-term patency of the CABG surgery.

Postoperative anticoagulation regimen

The anticoagulation protocol in our hospital includes aspirin and clopidogrel.

We give a 200 mg aspirin on the night of surgery and we start heparin of 500 U/hour when the chest tube drain is ≤ 50 ml/hour for 2 hours and continue for 48 hours. We then give a clopidogrel in 4 divided doses of 75 mg for four hours. After the patient was discharged following his drug dose with 200 mg aspirin and 75 mg clopidogrel [1]. Warfarin is used in some cases for 2-3 months with an INR ranging 2.5 to 3.5 [2]. Drug dose will be regulated after the follow-up.

Discussion 

Coronary artery endarterectomy is being performed in all the institutes with satisfactory results. The safety and long-term efficacy of the procedure, although controversial, has been demonstrated in both past and recent studies [3, 4, 5] the main indication for coronary artery endarterectomy is the presence of discursively diseased coronary arteries that are not suited for distal grafting [6]. With good surgical skills coronary artery endarterectomy could be safer and anticoagulation therapy that plays a crucial role in preventing postoperative myocardial infraction.

Comment

In diffused coronary artery disease performing a CABG always it has been a challenge. For obtaining good results surgeons been performing endarterectomy since few decades, even though ending up with unexpected results and complications. For complete endarterectomy, arterectomy need to be extended if necessary. Sewing the artery with a vein patch widens the coronary artery and increases the circulation. Coronary artery endarterectomy can be safe in skillful hands. Following a good anti-coagulant protocol shows good long-term results.

Reference

  1. Bailey CP, May A, Lewman WM. Survival after coronary endarterectomy in man. JAMA 1957; 164:641-6.
  2. Marzban M, Karimi A, Ahmadi H, et al. Early outcomes of double-vessel coronary endarterectomy in comparison with single-vessel coronary endarterectomy. Tex Heart Inst J 2008; 35:119–124.
  3. Livesay JJ, Cooley DA, Hallman GL, et al. Early and late results of coronary endarterectomy. Analysis of 3,369 patients. J Thorac Cardiovasc Surg 1986; 92(4):649–660.
  4. Brenowitz JB, Kayser KL, Johnson WD. Results of coronary artery endarterectomy and reconstruction. J Thorac Cardiovasc Surg 1988; 95(1):1–10. 
  5. Shapira OM, Akopian G, Hussain A, et al. Improved clinical outcomes in patients undergoing coronary artery bypass grafting with coronary endarterectomy. Ann Thorac Surg 1999; 68(6):2273–2278. 
  6. Asimakopoulos G, Taylor KM, Ratnatunga CP. Outcome of coronary endarterectomy: a case-control study. Ann Thorac Surg 1999; 67: 989–993.

Be the first to comment on "Coronary Artery Endarterectomy in Chinese Patients – Harvesting a Complete Plaque: A Case Report"

Leave a comment

Your email address will not be published.


*