Invited commentary

Abstract

Coronary endarterectomy (CE) is an important tool for the cardiac surgeon, because the number of patients with severe coronary artery disease continues to increase. To identify risk factors for adverse outcome after CE, Sirivella and colleagues [1Sirivella S. Gielchinsky I. Parsonnet V. Results of coronary artery endarterectomy and coronary artery bypass grafting for diffuse coronary artery disease.Ann Thorac Surg. 2005; 80: 1738-1745Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar] retrospectively compared a group of CE patients with a group of patients operated on with conventional coronary artery bypass graft surgery. Despite the fact that the patients in the CE group were at higher risk, with increased incidence of comorbidities and three-vessel disease, the operative mortality and the incidence of major postoperative morbidity were comparable between the groups. At long-term follow-up, actuarial survival and freedom from return of angina were also comparable between the two groups. The authors have to be congratulated for this extremely large series of CEs with good results. The study highlights some important aspects regarding the use of CEs. CE of the left anterior descending artery (LAD) had comparable outcome (ie, mortality and perioperative infarction rate) with CEs of the other major vessels. This finding may encourage the use of CEs in severely calcified LADs, and consequently, in my opinion, a wider use of the internal thoracic artery to revascularize this vessel. In the CE group, 60% of the myocardial infarctions were localized in the territory supplied by an endarterectomized vessel. Therefore I agree with the authors that, in patients in whom adequate CE is not feasable, CE should be used with caution. In such patients, alternative treatments such as transmyocardial revascularization or angiogenic growth factor have to be considered. The technique of endarterectomy, that is limited incision and traction versus an “open” technique, did not significantly influence results. This underlines that, in experienced hands, both techniques have a comparable, clinical outcome. Unfortunately, postoperative graft visualization and postoperative myocardial viability studies were not routinely performed in this study. Therefore, the question as to how much benefit CE adds to patients with diffuse coronary artery disease compared with conventional coronary surgery remains unanswered. Endarterectomy with bypass grafting is a well established therapy for all coronary arteries. In patients with a life expectancy of more than 10 years, a more aggressive use of arterial grafting, not only for the LAD, is justified because of the potential improvement of long-term results.