Diffuse coronary artery disease requires long coronary arteriotomy reconstruction as an adjunct to bypass grafting

Objectives: Myocardial revascularization procedures are increasingly used for end-stage, diffuse coronary disease with multiple prior percutaneous interventions. We present our surgical strategies to manage those heavily calcified target vessels that are technically most challenging.

Methods: Sixty-eight patients (59 male, age 67±8.7yrs) were treated with a total of 77 long coronary arteriotomy reconstructions (LCAR) across extensive atheromatous plaques with a length of 2.0±1.0cm (range 1.0–5.0cm). Vein or internal mammary artery grafts were used for reconstruction. Follow up [21±18 (3–75) months, 97% complete] included Canadian Cardiovascular Society (CCS) angina score, echocardiography, and occasional angiograms.

Results: Perioperative and long-term mortality was 2.9% and 4.4%, respectively. Fifty-nine (89%) patients became free of angina symptoms with CCS score of 0–1. One patient had a perioperative myocardial infarction, however, did not require further intervention. Only 5 patients showed mild hypokinesia of the myocardial territory supplied by the reconstructed coronary vessel, yet without elevated serum creatin-kinase as indicator of significant myocardial damage. Ejection fraction improved in 14 (20%) patients as early as 6 days post-op. Elective, occasional angiograms revealed a 100% graft patency rate. No patient required repeat coronary intervention during follow up.

Conclusions: Diffuse coronary artery disease can be managed with LCAR, and vein or mammary artery grafts as patches show excellent mid-term patency rates. Since this patient population will likely become the majority of surgical revascularization practice, further clinical investigation is required to compare the long-term patency rates of varying grafts and reconstruction techniques.