INVITED COMMENTARY

Abstract

Fukui and colleagues report in this issue, a series where in-stent restenosis has been removed at surgery by endarterectomy and arterial patch reconstruction using the pedicled left internal mammary artery. This raises numerous issues of importance to both surgeons and cardiologists. Where stents have been placed more distally, and are accessible to surgical removal, endarterectomy and arterial onlay patch angioplasty may be potentially curative. In-stent restenosis may be ameliorated by drugs or other agents attached to stents that suppress the growth of neointimal hyperplasia. But until abnormal vessel tissue is covered by a normal layer of endothelium at the time of or soon after stenting, restenosis can be expected in some. If the in-stent stenosis is removed, then flow competition from the native coronary circulation may cause inflow conduits to fail. Therefore, should the notion of arterial patch angioplasty (without an inflow conduit) be revisited? Much work remains to determine early success and later durability of the approach advocated by Fukui and colleagues. While flow to stent compromised side branches could be addressed by this technique, the relative indications for this approach over the theoretically simpler conventional coronary artery bypass grafting to branches distal to the in-stent stenosis, remain to be defined. Finally, coronary endarterectomy for diffusely stenosed coronary arteries was largely abandoned due to poor results and it is not very clear how this approach by Fukui and colleagues differs from that.