Outcomes of Patients Undergoing Coronary Endarterectomy within Coronary Artery Bypass Grafting: A 20-Year Single-Center Study

Objectives: Treatment of patients presenting with severely diffused coronary artery disease (CAD) is controversial. Coronary endarterectomy (CEA) has been introduced as a treatment-option for this end-stage pathology; many surgeons, however, avoid undertaking it due to reported ambivalent results.

Methods: Over a twenty-year period (March 1999–July 2019), 475 consecutive patients (age: 68 ± 9.2 years, male: 85.9%), presented with severely diffused CAD (mean SYNTAX-score: 35.2 ± 17.9) undergoing CEA within CABG surgery are evaluated. CEA was performed using a closed-traction technique. Study endpoints included early and late outcomes involving mortality and major adverse cardiac and cerebrovascular events (MACCE). Clinical follow-up was achieved using standardized questionnaire and was completed for 94.5% of the patients, reaching a mean follow-up time of 97.4 ± 47 months.

Results: Most of patients (91.6%) presented with three-vessel disease, 40.2% had previous myocardial infarction, 43.6% presented with impaired left ventricular function and 25.5% underwent nonelective surgery. A total of 4.2 ± 1.1 coronaries were grafted and 600 CEAs were performed, where 21.3% of patients required more than one CEA. Indication for CEA was either for completely occluded or suboccluded (caliber < 1.25 mm) vessels in 27 and 73% of cases, respectively. CEA target-vessel was the LAD-territory in 44.7%, CX-territory in 14.6%, and RCA-territory in 40.7% of cases. CEA-graft was venous in 61.3% and arterial in 38.7% of cases. Mean transit-time flow measurement for the CEA-graft was 67.1 ± 39.6 mL/min. Mean crossclamp time was 92 ± 26 minutes and concomitant procedures were done in 23.2% of patients. Postoperative outcomes reported 30-day mortality in 8% (4.4% for isolated CABG), myocardial infarction in 1.7%, need for re-CABG in 0.2%, and stroke in 3.5% of the patients, respectively. Late outcomes showed an overall incidence of MACCE in 40.4% of patients at last follow-up and incidence of mortality in 21.5% and 29.9% of patients at 5 and 10 years, respectively.

Conclusion: Patients with end-stage CAD are high-risk candidates for surgical revascularization and often judged inoperable. Although, CEA is a complex procedure, good short- and long-term results can be achieved. Closed traction-CEA with distal second incision and subsequent anastomosis in case of disrupted CEA-cylinder is our preferred method to allow revascularization when myocardium still viable.