الفهرس 
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Abstract
Patients with complex coronary artery disease are candidates for
coronary artery bypass grafting. Coronary endarterectomy as an adjunct
technique to CABG could be used in a patient with diffused CAD for receiving
complete revascularization.
Coronary endarterectomy is an old procedure which was designed to
treat coronary artery stenosis by removing the atherosclerotic plaques causing
the stenosis from inside coronary arteries rather than bypassing the stenosis.
In its earlier days, endarterectomy results were discouraging and were
overshadowed by the success of CABG in treating ischemic heart disease.
However with advances in perioperative care and mechanical circulatory
support, it has been revisited as an adjunct to conventional CABG in treating
patients with diffuse coronary artery disease.
Left anterior descending artery endarterectomy can be done by one of
two most famous methods which are namely the closed and the open
endarterectomy. In the closed endarterectomy a small arteriotomy is done and
blind controlled traction applied on the atherosclerotic plaque in order to deliver
it from the arteriotomy. In the open method a generous arteriotomy is created to
be able to dissect and pull out the atherosclerotic plaque from the coronary
artery under direct vision. This large arteriotomy is then reconstructed using the
internal mammary artery itself as an onlay patch or using a patch fashioned from
saphenous vein with the internal mammary artery then anastomosed to it.
The purpose of this study is to determine the impact of CE method on
early clinical outcomes of patients undergoing CABG with CE and to identify
independent risk factors of adverse outcomes by comparison both groups of
patients undergoing CE by the two methods; group A (20 patients): open LADCE versus group B (20 patients): closed LAD-CE.
In summary, patients with extensive and diffuse coronary artery disease
are high-risk candidates with coexisting morbidities. Myocardial
revascularization procedure in such a group is challenging without CE. This
study indicated that despite higher risk profile, both short-term and mid-term
outcomes after open CE with CABG are either comparable or were similar to
closed CE with CABG. In selected individuals with diffuse coronary artery
disease; CE still remains a surgical tool for complete myocardial
revascularization with an acceptable outcome, which may further be improved
Summary
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by either eliminating or modifying several risk factors that result in adverse
postoperative outcomes.
Although improved surgical techniques and better patients selection, the
improvements in CABG safety that account for this change; are superior
myocardial protection, use of antithrombotic therapy, standard grafting with the
internal mammary artery, and the availability of ventricular assist devices that
all led to a better postoperative outcome.
At the same time, there has been a dramatic change in the patient
population referred for CABG; an increasing number of patients who are
elderly, female, or diabetic and who are seen at more advanced stages with
diffuse distal coronary disease. In these situations, adequate revascularization is
often not possible by standard CABG alone, an adjunctive Coronary
endarterectomy allows the patient to achieve the long-term clinical benefits of
conventional bypass grafting by making ungraftable vessels suitable for bypass.
Among the two LAD endarterectomy techniques, the long arteriotomy
technique has the advantage of ensuring total plaque removal but typically
requires a longer aortic cross-clamp time because of the need to sew the vein
patch to the LAD endoarterectomized bed. The small arteriotomy technique has
the advantage of a shorter cross-clamp time, although; the difference in time not
reaching statistically significant difference, but the surgeon must be assured that
the entire plaque is removed with proper distal tapering. If distal tapering is not
observed, the arteriotomy should be extended to ensure complete plaque
removal.
The early results confirm the lasting benefits of endarterectomy in terms
of late survival, freedom from angina, and improving ejection fraction of
contractility of heart. In addition, this study suggests that methods of coronary
endarterectomy is nearly matched in terms of early outcomes.
The privileged method of endarterectomy based on surgeon personal
decision. Both open and closed endarterectomy can be performed on the LAD
but open endarterectomy is preferred to closed one by most of surgeons.