| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
|
Interact CardioVasc Thorac Surg 2009;9:738. doi:10.1510/icvts.2009.210633A © 2009 European Association of Cardio-Thoracic Surgery
eComment: How to reconstruct endarterectomized left anterior descending coronary artery‘Dedinje’ Cardiovascular Institute, Milana Tepica 1, 11000 Belgrade, Serbia Surgical extraction of occluded stents: when stenting becomes a problem We read with great interest the report by Atoui and colleagues [1] as they have brought up a problem of over-stenting of the diffusely diseased left anterior descending (LAD) coronary artery to our attention. Because of the increasing use of multiple stents in diffuse and distal lesions of the coronary arteries, cardiac surgeons are facing an enhanced number of patients with ‘full metal jacket’ coronary artery beds [1]. Under these circumstances, an endarterectomy of such vessels has often been considered an essential adjunct to achieve complete revascularization. We would like to congratulate the authors for the successful treatment of this complication. However, in our opinion, neither the technique they have reported is novel, nor the choice of venous patch to reconstruct the endarterectomized LAD is preferable than in situ left internal thoracic artery (LITA) on-lay patch. Although Atoui and associates [1] reported that stents were carefully dissected from the adventitial and removed, their procedure ended up as an endarterectomy (to be more precise, during endarterectomy external elastic lamina and adventitial tissue are left in place). Demirsoy and coauthors [2] have earlier reported an open endarterectomy of the LAD to remove previously implanted stents. The arteriotomy was closed with a saphenous vein patch, and the LITA was anastomosed onto it in end-to-side fashion [even the extracted samples (atheromatous core plus stents) are about the same length – 9 cm]. Santini and colleagues [3] have recently presented a series of 83 patients in whom segmental reconstruction (with or without endarterectomy) of the LAD had been performed with saphenous vein patch with LITA anastomosed onto it. The major concern with this technique is the degree of compliance of the three different components: the native artery, the saphenous vein patch, and the LITA. The compliance of saphenous vein patch may be responsible for energy loss and poor run-off. Redundant vein patch may also adversely influence the flow patterns, and subsequent turbulence may decrease the flow velocity. Combined with poor run-off, clot formation may occur and progress with resultant thrombosis of the lumen. It has recently been reported that closing of an endarterectomized artery by an arterial patch improves re-endothelization (a sheep model of open carotid endarterectomy [4]). Shimokawa and associates [5] have recently evaluated vascular remodeling of the LAD following segmental reconstruction (with or without endarterectomy) with the LITA within one year after surgery. Their results confirmed that the diameter of the reconstructed LAD decreased to become equivalent to the diameters of the LITA and distal LAD within one year after surgery. These results have also suggested that the LAD reconstructed with the LITA remodels physiologically over time, in a manner similar to the LITA graft. Although endarterectomy did not affect the remodeling, these findings suggested that the LAD coronary bed had been reconstructed with the LITA over a long segment remodeling over time. It is possible that vascular remodeling of grafted LAD may provide high long-term patency rate in severely and diffusely diseased coronary arteries that are not graftable using standard surgical techniques.
Related Article
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
Top
References