Invited commentary

Abstract

The authors report a low perioperative mortality and myocardial infarction incidence in a large series of patients having left anterior descending artery (LAD) endarterectomy. We and they have reviewed recent experience with coronary endarterectomy to place it in perspective with transmyocardial laser revascularization and the experimental methodology of induced angiogenesis. Conservative indications for endarterectomy of no vessel lumen or failure to pass a 1-mm probe were used and are similar to mine. I avoid endarterectomy if there is a 1.5-mm lumen in the LAD or its branches, and will occasionally graft a 1.0-mm healthy coronary artery, but not a larger coronary with a 1.0-mm lumen, and only with an arterial conduit. Patency data after endarterectomy of the LAD or other major targets are incomplete, but clearly there is reduced patency to 5 years compared with that obtained with saphenous vein or internal thoracic artery grafts to nonendarterectomized coronary arteries. This report on LAD endarterectomy and four others (from Boston, London, Ottawa, and St. Louis) on endarterectomy have appeared in The Annals over the past 5 years. In concert they indicate that perioperative morbidity and mortality have approached that of patients having coronary bypass without endarterectomy despite greater preexisting comorbidity in the former patients. Five-year survival of 70% to 90% in these reports reflects the broad range of clinical presentations in relatively small series of patients with advanced coronary disease. Importantly, it is clear that there is a role for endarterectomy in the management of patients in whom extensive and diffuse disease precludes usual coronary bypass. Traction technique with a small incision will work in many instances, but there must be willingness for incision extension or for a counterincision when examination of the specimen reveals that the end is not tapered but is an abrupt torn edge. Use of the left internal thoracic artery for the LAD is indicated and additional arterial conduit appropriate when there is the potential for survival to at least 6 years. Endarterectomy with bypass grafting is appropriate therapy for all of the coronary arteries, particularly the right and the LAD, with the latter no longer associated with poorer outcomes.