The “coronary dome arterial rebuilding", an original coronary total arterial endarterectomy technique. Surgical aspects and late outcomes

The increasing referral of patients with diffusely diseased coronary arteries for revascularization has renewed interest in coronary endarterectomy(EA).Here we present our experience with an original total arterial reconstruction technique for coronary EA. Materials and Methods: Between 2000-2012, 439 consecutive patients (307 men, mean age 59.5±12.3years) underwent an original EA called “coronary dome arterial rebuilding”. Following extensive arteriotomy (mean 4.4±0.7cm for the LAD, 3±0.6 cm for the OM and 3.2±0.7cm for the RCA) and atheroma remotion (eventually extended to collateral braches),the dome of the coronary artery was reconstructed with an adequate flap graft of skeletonized IMA for the LAD(58%)and the OM(23%)and of radial artery for the RCA(10%).The remaining part of the native endarteromized artery forms a posterior gutter giving the origins of collaterals branches. 9 of patients underwent coronary EA in multiple distributions. Mean 2.2±0.3 arterial grafts/patient were employed. 53% patients underwent total arterial myocardial revascularization. The mean follow-up was 45±23months. Results: Hospital mortality was 3.6% (n=16). Twenty (4.5%) patients had a perioperative myocardial infarction (MI), of whom 11 in the territory of the endarterectomized vessel. Multiple logistic regression analysis identified prolonged AoX time and EF<30% as independent predictors of perioperative death and MI (OR=2.6,CI=1.87-3.9,p<0.001; OR=1.2,CI=1.05-1.39,p<0.01, respectively). Within one year after surgery all patients ergometric test and 80% underwent coronary angiography. 14 endarterectomized vessels were occluded (5 LAD, 4 OM and 5 RCA; p=0.56). At follow-up, survival was 95.4% , with most (93%,) of the patients symptoms free. In symtomatic patients (n=33,), re-catheterization showed a progression of disease in the nonendarterectomized vessels and/or in the vein grafts, and 100% patency in bypass grafts to endarterectomized vessels.. Cumulative actuarial survival at 7 years was 96.3% and free-event cumulative survival was 93%. The Cox model revealed the LVEF<35%(p=0.016), age>70 years(p=0.025), NYHA grade>III (p=0.0019), non TAMR(p=0.002) and the preoperative presence of more than one ischemic area(p<0.001) as strong predictors for poor overall cumulative free-event survival. Conclusions: This technique enhances the probability to achieve a complete and arterial revascularization in patients with an unfavourable anatomical substrate with acceptable operative risk and good long-term results. The predictors for poor overall free-event survival seem to be similar to the general population undergoing conventional CABG.