Coronary "open" endarterectomy and reconstruction: short- and long-term results of the revascularization with saphenous vein versus IMA-graft.

From June 1984 to December 1990, 96 patients underwent "open" coronary endarterectomy and reconstruction. In 50 patients (group 1), a saphenous vein (SV) graft was used to reconstruct and bypass 54 coronary vessels. In 46 patients (group 2), 46 coronary vessels were reconstructed with an SV patch and then bypassed with the internal mammary artery (IMA): Seventy-four LAD coronary arteries (36 in group 1 and 38 in group 2) were treated with these procedures. Operative mortality was 8% in group 1 and 2.1% in group 2. Five patients (10%) in group 1 and 1 patient (2.1%) in group 2 developed perioperative myocardial infarction. The early postoperative patency of the reconstructed vessels was 84.6% in group 1 and 92.5% in group 2. Angiographic controls were performed between 30 and 36 months after operation in 18 patients (72%) of group 1 and in 16 patients (69%) of group 2 with patency rates of 66.7% and 81.5%, respectively. A further angiographic study performed between 54 and 60 months after operation of 9/22 patients of group 1 and 5/9 patients of group 2 did not show any additional closure of the endarterectomized vessels. Three- and 5-year survival analyzed by the Kaplan-Meier method was 79.6% and 69.7%, respectively, in group 1 and 86.8% for both the 3- and 5-year survival in group 2. After a mean follow-up of 51.0 and 35.5 months, 62.8% of the surviving patients of group 1 and 75.6% of group 2 were asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary revascularization with arterial graft alone]

In the period from December 1989 until July 1991, coronary revascularization were performed on 56 patients using arterial grafts and no venous grafts. The ages of the patients ranged from 43 to 85 years (average; 66.8 years), and there were 33 males and 23 females. Twenty-four patients had angina pectoris, 23 had old myocardial infarction and 9 had acute infarction. There were 3 patients with single-vessel coronary disease, 19 with double-vessel, 31 with triple-vessel and 9 with left main coronary disease. The bypass grafts used were 58 left internal thoracic artery (LITA) grafts, 29 right internal thoracic artery (RITA) grafts, and 56 right gastroepiploic artery (RGEA) grafts. Thus, 143 grafts were used and an average of 2.6 bypasses were created per patient. There were two operative deaths. One of these patients had acute myocardial infarct. Investigation of postoperative graft patency was performed in the 122 grafts that could be examined angiographically after surgery. Only 7 were obstructed, yielding a patency rate of 94.3%. By using both the ITA and RGEA, in situ anastomoses with all the coronary arteries could be performed. Also in emergency surgery arterial grafting was possible. This operative form is considered to be a useful technique and may be expected to produce favorable long-term results.     

Coronary endarterectomy

From July, 1984, to December, 1986, coronary bypass grafting was performed in 314 patients, 70 (22%) requiring coronary endarterectomy (RCA; 48 pts, LAD; 10 pts, LAD + RCA; 10 pts, Others; 2 pts). Coronary endarterectomy patients (END group) were younger and often with the risk factor of hyperlipidemia than non-endarterectomy patients (NON group). The over-all hospital mortality rate of END group was 7 per cent; perioperative myocardial infarction occurred in 7 per cent of patients. Early postoperative angiogram (4 weeks after the operation) was performed in 54 patients. The patency rate of RCA endarterectomy was 81.8 per cent, and that of LCA endarterectomy was 75 per cent. This result was poor compared with the patency rate of non-endarterectomy graft (86.6%). However without endarterectomy, with all likelihood the patency rate of those grafts would have been poorer. The results of right coronary endarterectomy are satisfactory and better than those of the left coronary artery system. This experience suggests that coronary endarterectomy is safe and an useful adjunct of saphenous vein bypass grafting procedures in the management of diffuse coronary disease, especially in RCA lesions.     

Combined carotid endarterectomy and myocardial revascularization

From February 1971 through December 1987, 95 patients underwent combined carotid endarterectomy and myocardial revascularization. Mortality and postoperative stroke rates were 4 percent and 2 percent, respectively, for the 16-year experience. From 1980 to 1987, when 89 percent of patients had their operation, mortality and stroke rates were 1 percent and 2 percent, respectively. Follow-up carotid duplex scan in 41 patients revealed that 25 percent had more than 50 percent restenosis. Only two in this group were symptomatic. We conclude that the combined approach to concomitant carotid and coronary artery atherosclerosis can be done safely. Continued study with noninvasive testing is important to document restenosis rates.     

Simultaneous carotid endarterectomy and coronary revascularization

BACKGROUND: Combined cardiac operation and carotid endarterectomy using our technique is an acceptable approach to simultaneous correction of both carotid and cardiac disease. METHODS: From August 1989 to March 1998, 121 consecutive patients underwent combined operations. Of these patients, 112 had coronary artery bypass grafting and carotid endarterectomy, and 9 had coronary artery bypass grafting, carotid endarterectomy, and valve repair or replacement. All patients had a critical stenosis of 85% or more of the carotid artery. Mean age of the patients was 69.2 years; 80 patients were 65 years old or older. There were 88 men and 33 women. Notable risk factors included chronic obstructive pulmonary disease (19.8%), congestive heart failure (28%), preoperative myocardial infarction and unstable angina (66.9%). Of the patients, 20.7% had a stenosis of greater than 50% of the left main coronary artery. The technique used was correction of both the carotid and coronary lesions during a single aortic cross-clamp period using retrograde continuous blood cardioplegia for myocardial protection. Systemic hypothermia to 25 degrees C was used for cerebral protection. RESULTS: Mean cross-clamp time was 118 minutes. Seven patients (5.8%) sustained perioperative cerebrovascular accidents. Two patients had transient ischemic attacks. The procedure-related mortality rate was 5.8%. CONCLUSIONS: The described technique is a good method for simultaneous repair of coronary and carotid lesions in a high-risk group of patients with concomitant disease. We will continue to use it.     

Myocardial revascularization before carotid endarterectomy

Diffuse atherosclerosis involving more than 1 vascular bed is a challenging problem. The natural histories of carotid and coronary atherosclerosis are clearly intertwined. The optimal strategies for treatment of patients who present with carotid artery stenoses and co-existent coronary artery disease (CAD) remain controversial. Minimally invasive screening tests for CAD are often unreliable, and patients presenting with significant extracranial carotid artery stenoses should usually be assumed to harbor some degree of CAD. Numerous studies have confirmed, however, that in contrast to peripheral artery stenoses, hemodynamically significant stenoses of the coronary arteries are not necessarily the index lesions that produce myocardial infarctions (MIs). Although there are some anecdotal reports that myocardial revascularization prior to carotid endarterectomy (CEA) improves the short- and long-term cardiac outcomes of patients after CEA, no prospective, randomized, controlled studies have proven this hypothesis. Numerous adverse cardiac events can occur in the perioperative period including congestive heart failure (CHF), arrhythmias, unstable angina pectoris and both nonfatal and fatal MIs. Of these, only MIs are truly "hard" endpoints. The incidence of MI after CEA is much lower than after other commonly performed peripheral arterial operations such as aortic or infrainguinal procedures. The perioperative nonfatal and fatal MI rates after CEA average about 1.0% and 0.4%, respectively. The Coronary Artery Revascularization Prophylaxis (CARP) study is currently ongoing in the United States as a multicentered randomized prospective controlled trial sponsored by the Department of Veterans Affairs. In this study, patients with significant CAD who are undergoing operations for peripheral arterial disease are randomized to myocardial revascularization versus best medical care; however, CEA procedures are excluded from this study because cardiac morbidity is low. Based on the low incidence of adverse cardiac events in CEA patients, it is generally prudent to treat their CAD with best medical care rather than routine prophylactic myocardial revascularization.     

Coronary revascularization with bilateral internal thoracic artery grafts]

Thirty-two patients underwent coronary revascularization with bilateral internal thoracic artery (ITA) grafts. Each patient received 2.7 grafts in average including double ITA grafts. Seventeen patients had the right ITAs as free grafts. The other sixteen were treated with 13 autologous veins and 9 right gastroepiploic arteries in addition. Fifty-five grafts out of 56 (98.2%) were proved to be patent at the time of hospital discharge. The postoperative morbidity included three reoperations for bleeding and one perioperative inferior myocardial infarction. One patient died of colon perforation after surgery and another died of cerebral infarction late after surgery. These results exhibited that coronary artery bypass grafting with bilateral ITA grafts had relatively low risks and could contribute to complete revascularization in patients with diseased coronary arteries.     

Coronary artery revascularization after chest wall reconstruction with rectus abdominis myocutaneous flap

The standard incision for a cardiac operation is a median sternotomy. In special situations, alternative approaches are needed. We report a 53-year-old woman who required coronary artery bypass grafting 10 days after chest wall reconstruction with a transverse rectus abdominis myocutaneous flap. We describe our technique, which allowed us to preserve the flap and resulted in good functional and aesthetic outcome.     

Off pump concomitant coronary revascularization and carotid endarterectomy

AIM: Off pump coronary revascularization has emerged as a viable option in the treatment of coexisting clinically significant carotid and coronary artery disease. To this end, we report our recent experience with combined carotid endarterectomy (CEA) and off pump coronary artery bypass (OPCAB). METHODS: Our prospectively updated database was queried to identify all patients who underwent combined OPCAB/CEA between January 1, 1999 and December 31, 2002. A total of 38 patients were identified. They were subsequently compared to a contemporaneous cohort of isolated off-pump patients divided into those with and without cerebrovascular disease (CVD). RESULTS: Mean age of the study population was 71+/-7.0 years, 23 patients (58%) had significant left main disease, 5 (13%) suffered a previous stroke and 5 (13%) had ejection fractions 相似文献   

Coronary revascularization in septuagenarians

Despite a 15 year experience with the aorta-coronary bypass operation, indications for its use remain unsettled, especially in the elderly. Between January, 1974, and June, 1980, 2,667 patients underwent coronary artery revascularization with an overall mortality of 3.8% (101/2,667). During the last 12 months the mortality has decreased to 1%. There were 2,562 patients below the age of 70, with a mortality of 3.5% (90/2,562), in contrast to 105 patients over the age of 70, with a mortality of 10.5% (11/105) (p = 0.002). In patients less than 70 years of age there was a significant difference between the mortality of men, 3.12% (67/2,146), and that of women, 5.53% (23/416) (p = 0.015). This disparity of operative risk was far more pronounced in patients over 70 years of age: men 6% (5/84) and women 28.6% (6/21) (p = 0.002). The overall operative mortality of women, 6.6% (29/437), was significantly different from the overall mortality of men, 3.2% (72/2,230) (p = 0.001). An in depth analysis of past medical history, risk factors, and catheterization data is presented in those patients over the age of 70. The average number of vessels bypassed was 2.40: men 2.47 and women 2.09 (p = NS). The ages varied from 70 to 81 years with a mean of 72.5. Smoking (p = 0.012) and diabetes (p = 0.0078) were significant risk factors for coronary disease. Smoking (p = 0.032) and abnormal pulmonary artery pressures (p = 0.0429) were significant variables affecting mortality. A 97.1% follow-up was obtained up to 78 months. Coronary artery revascularization can be performed in men below the age of 70 with acceptable mortality, but there is a twofold increase above the age of 70. Women can undergo revascularization below the age of 70 with a significantly higher risk than males. Those above the age of 70 are at severe risk and should undergo revascularization only after careful selection.     

Osteitis and reconstruction of shaft defects of long bones]

The results of treatment of 18 patients with post-inflammatory shaft defects of the long bones within the femur, the tibia, and the humerus have been presented. The defect ranged from 2 to 4 cm in most of the cases; it was 8 cm in one case, 10 cm in two cases and over 20 cm in two cases. The treatment method consisted in active, multidirectional surgical procedure overcoming the inflammatory process and changing the "infected" case into a "clean" one making possible to use the generally accepted treatment methods. Healing of grafts and bone union was obtained in all 18 cases, marked restriction of movement in the knee joint was found in 4 patients, and recurrence of the inflammatory process of mild clinical course was found in 4 cases.