Extended Endarterectomy is a Treatment Option for Diffuse Inoperable Left Sided Coronary Artery Disease

Background:Left coronary endarterectomy as an adjuvant to coronary artery bypass grafting (CABG), has been associated with increased morbidity and mortality with debated long term results. In previous literature, poor post-operative outcomes were skewed due to the lack of modern anti-platelet therapy. Furthermore, current literature focuses upon the left anterior descending (LAD) and negates the distal run off.
Objective: To investigate the short and long-term outcomes of a long left coronary artery branch endarterectomy (LLCE) as an adjuvant to CABG in the context of modern anti platelet therapy.
Methods: Retrospective analysis on a 120 prospectively collected patients undergoing LLCE, between 1999-2016 by a single surgeon, using a long open (2.5-4cm) dissection and venous patch. We compared outcomes with 120 propensity matched CABG patients using Cox’s regression analysis.
Results: Diffuse atheroma in the LLCE group was present in 57.5% (n=69/120) in the LAD, 34.1% (n=41/120) involved both LAD and branches of the circumflex artery (Cx) and 8.4% (n=10/120) involved Cx. Cross clamp time (43.29 v 59.04, p=0.019) and bypass time (57.29 vs 74.04, p=0.007) were significantly higher in the LLCE group. There was no significant difference in early (1% v 1.3%) and late mortality (4% v 4.5% at 10 years). The hospital length of stay (5.58 v 6.67 p = 0.03) was higher in the LLCE group.
Conclusion: LLCE coronary endarterectomy is a safe and reproducible strategy in patients with otherwise prohibitive atheroma burden. Despite increased cross clamp, bypass and in hospital patient times, freedom from all cause mortality is excellent.