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The Journal of Thoracic and Cardiovascular Surgery, Vol 92, 649-660, Copyright © 1986 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
JJ Livesay, DA Cooley, GL Hallman, GJ Reul, DA Ott, JM Duncan and OH Frazier
The effectiveness of coronary revascularization has been questioned in
patients with diffuse coronary disease. Over a 14 year period (1970 to
1984), 30,464 patients underwent surgical revascularization at our
institution. Coronary artery bypass alone was done in 27,095 patients and
was combined with coronary endarterectomy in 3,369 patients (12.4%).
Analysis of preoperative variables revealed an increased incidence of male
sex, diabetes mellitus, low ejection fraction (less than 30) and multiple
vessel disease in patients requiring endarterectomy. The early results
after revascularization indicated a small increase in surgical risk after
endarterectomy. The 30 day mortality for bypass alone was 2.6% versus 4.4%
for coronary endarterectomy (p less than 0.01). Multivariate analysis
identified independent predictors of operative risk: ejection fraction less
than 30%, reoperation, age, absence of hyperlipidemia, endarterectomy, and
female sex. Early mortality was significantly increased by endarterectomy
in the left anterior descending coronary artery (8.5%) compared to
endarterectomy in arteries other than the left anterior descending (4.2%)
(p less than 0.01). In a sample of 4,473 patients, myocardial complications
were also found to be increased after coronary endarterectomy. The
incidence of perioperative myocardial infarction in patients undergoing
bypass alone was 2.6% versus 5.4% for patients undergoing bypass plus
endarterectomy (p less than 0.01). Both fatal and nonfatal cardiac arrests
increased (bypass alone, 1.7%; endarterectomy, 3.5%; p less than 0.01).
This suggests the failure mode of unsuccessful endarterectomy. Early
mortality after coronary endarterectomy decreased substantially from
1970-1976 (6.4%) to 1977- 1984 (3.5%; p less than 0.01). Actuarial analysis
at 5 years and longer has shown very little difference in the long-term
survival rate (coronary bypass, 90%; coronary endarterectomy, 86%), freedom
from angina (coronary artery bypass, 58%; coronary endarterectomy, 52%),
and freedom from reoperation (coronary artery bypass, 97%; coronary
endarterectomy, 98%). Despite the small increase in surgical risk, the
early and late results support the selective application of coronary
endarterectomy in patients with diffuse distal disease and demonstrate the
beneficial long-term effects.
ARTICLES
Early and late results of coronary endarterectomy. Analysis of 3,369 patients
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