Bread and Butter

Few will dispute that a slice of tasty dark bread covered by a generous layer of yellow high-quality butter, maybe enhanced with a pinch of sea salt crystals, makes an excellent snack: nourishing, healthy, and refreshingly basic. As a figure of speech, “bread and butter” has become synonymous with just that – basic quality. In cardiac surgery, the bread and butter business has been coronary artery surgery for decades.

Many times doom has been called upon it by the cardiologists with every arrival of a new stent generation: bare metal, drug-eluting, and now absorbable. Surgeons have usually remained rather cool, as is their wont. They simply know that digging foreign material into the highly active endothelium will cause problems, especially in the one to two millimeter diameters in question. If you bury a chip of metal in your thumb while filing something it will vanish without a trace at first. Not much later a vulnerable, reddish nodule will appear, and finally this is bound to break open and release the culprit. This is a life-saving defense mechanism called foreign-body-reaction. Coronary stents are high-tech metal chips and vascular endothelium is generally more active than the epidermis or subcutis of a finger. This is why absorbable scaffolds were developed. Rest assured: along with the stents trouble is already on its way. Surgeons have been using absorbable sutures for a very long time. Even with seemingly inert polymers such as the ether-ester units of polydioxanone, resorption means that the parts have to go somewhere. Again, it is the body who has to do the work. In neonatal surgery polydioxanone was welcomed to avoid potential strictures of delicate anastomoses in growing vessels, for instance in the correction of coarctation or in the arterial switch procedure. Whereas fine, non-absorbable polypropylene will break during growth, polydioxanone will disappear, but at the cost of an inflammatory reaction around the suture line. Which do you prefer?

So coronary artery surgery is here to stay - with an average number of around 50.000+ procedures per year in Germany alone. In theory, this number should be steadily increasing what with the growing evidence that surgery has a better long-term outcome than percutaneous coronary intervention (PCI), especially in multi-vessel disease. The fact that it is not (yet), has to do with the immensely different invasiveness of the two potential treatment methods. A prick in the groin and home the next day at the latest - versus a sawed-through sternum, strange incidences on an intensive care unit in the small hours of the night, and weeks of recuperation and discomfort. Seems like an easy choice. With a high price to pay and, admittedly, a risk of rather nasty adverse effects at the beginning, the reward comes with the long term patency and survival, something not very many patients seem to be interested in. This is a bewildering finding, because for oncology patients exactly this is their primary goal.

Coronary artery surgery, as every surgery, must be tailored individually to the patient. Whereas there is little doubt that a predominantly or exclusively arterial revascularization does yield the best long-term results, it cannot be denied that stripping down both mammary arteries does rob the sternum of a fair amount of its blood supply. And this poor bone has just been equipped with a set of wires to hopefully hold it together while healing. It is therefore fair that whenever one advocates modern coronary artery surgery, one should also openly discuss the potential problems associated with it. Fortunately we do learn from and with our patients and this is resulting in the constant further development of sternal osteosynthetic techniques.

All of this may not be as spectacular as a fancy high-tech vanishing scaffold but seems rather down to earth instead. Surgeons, however, have been known for a long time to esteem the solidity of their workmanship – like crusty bread and tenderly melting butter.