TCT-637 19-Year Outcomes of Total Arterial Reconstruction After Coronary Endarterectomy in 948 Patients

Pandemic diabetes has increased the incidence of patients with severely diffused calcified coronary artery disease. We investigated long-term outcomes in patients undergoing endarterectomy (EA) followed by total arterial coronary vessel reconstruction. Methods All consecutive 948 patients undergoing EA followed by total arterial coronary vessel reconstruction between June 1997 and July 2023 were included. Reconstruction was performed using a technique called coronary-dome arterial rebuilding (EA-CAR) with the dome of the coronary artery reconstructed with a flap graft of skeletonized LIMA for the LAD and the obtuse marginal (OM) coronary artery. A radial artery graft was used for the reconstruction of the right coronary artery (RCA). Patient selection was done based on heart-team decision. Results Mean age 61.4 ± 13.7 years and 726 (76.6%) patients were men. Intraoperatively, mean arteriotomy extension was 4.3 ± 0.8 cm for the LAD, 3.3 ± 0.7 cm for the OM, and 4.2 ± 1.1 cm for the RCA, while 2.6 ± 1.5 arterial grafts x patient were employed. LAD reconstruction was performed in 58% of cases, OM in 23%, and RCA in 10%. A total of 69 (73%) patients underwent EA-CAR in multiple distributions while 597 (63%) patients underwent total arterial revascularization. 30-day outcomes included all-cause hospital mortality 1.9% (n = 18), myocardial infarction 1.8% (n = 17) of whom 12 (70.6%) were in the territory of the EA-CAR vessel, cerebrovascular accident 1.2% (n = 11), and major respiratory complications 4.6% (n = 44). Predictors of perioperative death were prolonged cross-clamp time (>150 min) and left ventricular ejection fraction <35%. Mean follow-up was 19.8 ± 6.5 years and included all-cause mortality of 6.9% (n = 64), repeat revascularizations 8.9% (n = 83), and major adverse cardiac and cerebrovascular events 14.5% (n = 135). In symptomatic patients (n = 89), repeat catheterization showed disease progression in the non-endarterectomized vessels (n = 33) and/or in the vein grafts (n = 56), and 94% patency in grafts bypassing endarterectomized vessels. Conclusion This technique enhances the possibility to achieve a complete and arterial revascularization in patients with an unfavorable anatomical substrate, acceptable operative risk, and good long-term results, similar to non–EA-CAR CABG patients.