Interactive CardioVascular and Thoracic Surgery 19 (2014) 848–855 doi:10.1093/icvts/ivu261 Advance Access publication 11 August 2014
BEST EVIDENCE TOPIC – ADULT CARDIAC
Does coronary endarterectomy technique affect surgical outcome when combined with coronary artery bypass grafting? Erdinc Soylu, Leanne Harling*, Hutan Ashrafian and Thanos Athanasiou Department of Surgery and Cancer, Imperial College London, London, UK * Corresponding author. Department of Surgery and Cancer, Imperial College London, 10th floor QEQM Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK. Tel:+44-203-3127651; fax: +44-203-3126302; e-mail:
[email protected] (L. Harling). Received 4 June 2014; accepted 10 July 2014
Abstract A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether open coronary endarterectomy (CE) and coronary artery bypass grafting (CABG) compares favourably with closed endarterectomy and CABG in the myocardial revascularization of patients presenting with diffuse coronary artery disease (DCAD). One hundred and fifty-five articles were identified by a systematic search, of which 10 best answered the clinical question incorporating a total of 1203 patients (915 open-CE, 288 closed-CE). All were observational studies. Two were comparative and the remaining eight were case series. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and results were recorded. The open technique involved removal of atheroma under direct vision through an arteriotomy along the length of diffusely stenotic artery, whereas the closed technique involved a smaller arteriotomy and removal via traction on the proximal plaque. The overall postoperative mortality rate associated with open-CE ranged from 2.3 to 10.5%. Both comparative studies demonstrated at least equivalent 30-day mortality between open-CE and closed-CE. Notably, the four studies with highest overall postoperative mortality used a saphenous vein (SV) graft in the majority of patients. Furthermore, two-vessel CE was associated with higher mortality rates. Among these best evidence series, the overall incidence rate of postoperative myocardial infarction (MI) was 7.3% (88/1203). Whether open-CE or the use of internal thoracic artery (ITA) conduit over SV affects postoperative MI rates remains inconclusive. Mid-term and long-term graft patency, and 3-, 4- and 5-year survival rates are all improved when open-CE is combined with the ITA bypass conduit, when compared with closed-CE or open-CE using another conduit. In summary, open-CE with CABG in the setting of DCAD may carry lower 30-day mortality than closed-CE with CABG. Utilization of ITA appears to improve mortality, whereas the SV conduit and multivessel CE may worsen clinical outcome. Furthermore, the ITA may also improve graft patency when combined with open-CE. There is currently insufficient evidence to determine the effect of open-CE on MI incidence. Future large, prospective studies are now required with defined subgroups, stratifying technique, number and territory of the endarterectomy and conduit type in order to determine the patients in whom open-CE may confer the greatest benefit. Keywords: Open • Coronary • Endarterectomy
INTRODUCTION A best evidence topic was constructed according to a structured protocol as fully described in the ICVTS [1].
THREE-PART QUESTION In [ patients with diffuse coronary artery disease] is [open coronary endarterectomy with CABG] or [closed coronary endarterectomy with CABG] the best technique in terms of [mortality and freedom from myocardial infarction]?
descending artery (LAD) stenosis. Transthoracic echo was grossly normal with an ejection fraction of 56%. You are asked to consider her for elective CABG, and may have to perform coronary endarterectomy (CE). Your trainee asks whether you would use an ‘open’ or ‘closed’ technique?
SEARCH STRATEGY A literature search was performed using PubMed, Ovid, Embase and Cochrane databases using the terms ‘open’, ‘extensive’ ‘coronary vessels’, ‘heart’ and ‘endarterectomy’. The last search date was 24 February 2014.
CLINICAL SCENARIO SEARCH OUTCOME A 60-year old female with a history of stable angina is referred with worsening exertional chest pain. Percutaneous coronary angiogram revealed a long segment of diffuse left anterior
One hundred and fifty-five articles were found of which 10 [2–11] provide the best available evidence (Table 1).
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
E. Soylu et al. / Interactive CardioVascular and Thoracic Surgery
849
Table 1: Best evidence papers Author, date, journal and country Study type (level of evidence)
Patient group
Nishi et al. (2005), Ann Thorac Surg, Japan [9]
68 patients (mean age 64.9 ± 9 years, 30.8% male) undergoing open-CE + CABG compared with 59 patients (mean age 63 ± 8 and 2% male) undergoing closed-CE + CABG between 1994 and 2003
Mortality
Number of diseased vessels: 2.8 ± 0.5 in open-CE + CABG vs 2.9 ± 0.3 in closed-CE + CABG (P 0.05)
MI
Perioperative MI = 2 (2.9%) in the open-CE vs 2 (3.4%) in the closed-CE group
CVA
CVA = 2 (2.9%) in the open-CE vs 0 (0%) in the closed-CE group (P >0.05)
Limitations:
IABP
IABP = 4 (5.9%) in the open-CE vs 7 (11.9%) in the closed-CE group (P >0.05)
Retrospective observational study design. No exclusion criteria
Infection
Infection = 2 (2.9%) in the open-CE vs 4 (6.8%) in the closed-CE group
Re-exploration
Re-exploration for bleeding: 3 (4.4%) in the open-CE vs 3 (5.1%) in the closed-CE group
Patency
Early angiographic results: 58/63 (92.1%) of grafts in the open-CE vs 62/70 (88.6%) of grafts in the closed-CE group (P >0.05) were patent
Techniques: arteriotomy + open- versus closed-CE + LITA or SV onlay patch Open group: LAD (47), Cx (7), RCA (16), D (2); SV graft (29) ITA (54) RA (1) Closed group: LAD (24), D (5), Cx (10), RCA (37); SV graft (36) ITA (26) RA (2) GA (1) Number of distal anastomoses: 4.0 ± 1.3 in open-CE + CABG vs 4.5 ± 1.1 in closed-CE + CABG (P0.05). The incidence of postoperative myocardial infarction (MI), intra-aortic balloon pump use and stroke were lower with open-CE (2.9, 5.9 and 2.9%, respectively) than closed-CE (3.4, 11.9 and 0%, respectively; P >0.05). In their prospective study of 286 patients (57 open-CE; 229 closed-CE), Gol et al. [7] demonstrated improved mortality (8.8 vs 10.9%), postoperative MI (3.5 vs 13.9%), inotrope use (26.8 vs 30%), atrial fibrillation (AF) (3.5 vs 5.6%) and ventricular fibrillation (0 vs 3%) in open-CE when compared with closed-CE.
E. Soylu et al. / Interactive CardioVascular and Thoracic Surgery
CLINICAL BOTTOM LINE This review aimed to assess the safety and feasibility of open-CE versus closed-CE, with a view to improving morbidity and mortality outcomes in patients with DCAD requiring CE. Open-CE was associated with a postoperative mortality rate ranging from 2.3 [2] to 10.5% [7]. This was lower with open-CE than closed-CE in two comparative studies [7, 9]. Notably, the four studies with highest overall postoperative mortality used an SV graft in the majority of patients [4–7]. In comparison, studies using the ITA conduit generally demonstrated lower mortality rates [3, 4, 8, 10, 11]. Furthermore, two-vessel CE was associated with higher mortality than single-vessel CE [3, 4]. Among these best evidence series, the overall incidence rate of postoperative MI was 7.3%, with comparative studies demonstrating lower rates in open-CE than closed-CE [7, 9]. Whether open-CE or the use of the ITA conduit over the SV affects postoperative MI rates remains inconclusive, as although some studies have shown reduced MI with the ITA when compared with the SV [9–11], this is contradicted by other groups [8].
Mid-term graft patency [3, 9], long-term graft patency [3], and 3-, 4- and 5-year survival [3, 4] were all improved when open-CE was used in combination with the ITA bypass conduit. A number of limitations must be considered. All studies were non-randomized and retrospective. Five studies had patient numbers below 100. Variable patient selection criteria, surgical technique and surgeon experience may have an incalculable effect on short- and long-term outcomes. In summary, open-CE with CABG in the context of DCAD may carry a lower 30-day mortality than closed-CE with CABG. Utilization of the ITA may improve mortality, whereas the SV conduit or twovessel CE may worsen clinical outcome. There is currently insufficient evidence to determine the effect of open-CE on MI incidence; however, ITA use may improve graft patency when combined with open-CE. Future large, prospective studies are required with defined subgroups, stratifying technique, conduit type, and number and territory of the endarterectomy in order to determine the patients in whom open-CE may confer the greatest benefit. Conflict of interest: none declared.
REFERENCES [1] Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–9. [2] Sommerhaug RG, Wolfe SF, Reid DA, Lindsey DE. Early clinical results of long coronary arteriotomy, endarterectomy and reconstruction combined with multiple bypass grafting for severe coronary artery disease. Am J Cardiol 1990;66:651–9. [3] Beretta L, Lemma M, Vanelli P, DiMattia D, Bozzi G, Broso P et al. Coronary “open” endarterectomy and reconstruction: short- and long-term results of the revascularization with saphenous vein versus IMA-graft. Eur J Cardiothorac Surg 1992;6:382–6; discussion 387. [4] Christenson JT, Simonet F, Schmuziger M. Extensive endarterectomy of the left anterior descending coronary artery combined with coronary artery bypass grafting. Coron Artery Dis 1995;6:731–7. [5] Sankar NM, Satyaprasad V, Rajan S, Bashi VV, Cherian KM. Extensive endarterectomy, onlay patch, and internal mammary bypass of the left anterior descending coronary artery. J Card Surg 1996;11:56–60. [6] Tasdemir O, Kiziltepe U, Karagoz HY, Yamak B, Korkmaz S, Bayazit K. Long-term results of reconstructions of the left anterior descending coronary artery in diffuse atherosclerotic lesions. J Thorac Cardiovasc Surg 1996;112:745–54. [7] Gol MK, Yilmazkaya B, Goksel S, Sener E, Mavitas B, Tasdemir O et al. Results of right coronary artery endarterectomy with or without patchplasty. J Card Surg 1999;14:75–81. [8] Fukui T, Takanashi S, Hosoda Y. Long segmental reconstruction of diffusely diseased left anterior descending coronary artery with left internal thoracic artery with or without endarterectomy. Ann Thorac Surg 2005;80: 2098–105. [9] Nishi H, Miyamoto S, Takanashi S, Minamimura H, Ishikawa T, Kato Y et al. Optimal method of coronary endarterectomy for diffusely diseased coronary arteries. Ann Thorac Surg 2005;79:846–52; discussion 852. [10] Kato Y, Shibata T, Takanashi S, Fukui T, Ito A, Shimizu Y. Results of long segmental reconstruction of left anterior descending artery using left internal thoracic artery. Ann Thorac Surg 2012;93:1195–200. [11] Myers PO, Tabata M, Shekar PS, Couper GS, Khalpey ZI, Aranki SF. Extensive endarterectomy and reconstruction of the left anterior descending artery: early and late outcomes. J Thorac Cardiovasc Surg 2012;143: 1336–40.
BEST EVIDENCE TOPIC
Tasdemir et al. [6] retrospectively studied 61 patients undergoing open-CE to the LAD with SV patch and ITA bypass graft, SV-onlay graft or ITA-onlay graft reconstruction. The postoperative mortality rate was 6.5% (4/61) with MI occurring in 8.1% (5/61). The MI rate in the endarterectomized LAD territory was lower at 1.6% (1/61). Sankar et al. [5] retrospectively studied 69 patients undergoing open-CE to the LAD with either SV-onlay graft or ITA-onlay graft reconstruction. The postoperative mortality rate was 10.1% (7/69), with an MI incidence rate of 4.3% (3/69). In their retrospective series of 106 patients, undergoing open-CE to the LAD with either ITA-onlay graft or SV patch and ITA bypass, Christenson et al. [4] observed an overall mortality rate of 9.4% (10/106). Mortality was significantly lower with the ITA (5%) bypass conduit compared with the SV (12.1%). Two-vessel CE conferred a higher mortality (36.4%) than single-vessel CE (6.3%). The incidence rates of MI and CVA were 6.6% (7/106) and 1.9% (2/106), respectively. MI rates were lower in patients receiving ITA as the bypass conduit. Beretta et al. [3] retrospectively studied 96 patients who underwent open-CE to the LAD (74), right coronary artery (RCA) (22) and circumflex artery (CA) (4) with SV patch and ITA bypass graft or SV-onlay graft reconstruction. The overall mortality rate was 5.2% (5/96) but this was lower (2.1%) with the ITA bypass conduit when compared with the SV (8%). Two-vessel CE conferred a higher mortality (11.7%) than one-vessel CE (3.7%). Postoperative MI (6.3%) and neurological injury (2%) were lower in patients receiving ITA (2.1 and 0%, respectively) as the bypass conduit. Sommerhaug et al. [2] retrospectively studied 130 patients undergoing open-CE to the LAD (121), RCA (18) and CA (13) with SV or ITA bypass graft reconstruction. Overall 30-day mortality was 2.3% (3/130), with a low incidence of MI 1.5% (2/130).
855
