Coronary endarterectomy found to be reliable treatment for advanced artery disease

January 18, 2000

Medical treatments often fall out of favor after they have been used for a while and newer treatments become available. For example, a surgical procedure for cleaning out the coronary arteries that was developed in the 1950s is used much less frequently today than coronary bypass surgery. But as the population grows older, cardiologists are seeing more patients with advanced artery disease who are ineligible for bypass operations. Now researchers at Washington University School of Medicine in St. Louis have determined that many of these patients might benefit from the older procedure, coronary endarterectomy. To perform this endarterectomy, surgeons open up the chest, cut open the blocked coronary artery, remove the blockage, and sew up the artery wall. The researchers determined outcomes of 177 patients who underwent this procedure between 1986 and 1997 at Washington University Medical Center. "We concluded that coronary endarterectomy can be performed with an acceptable risk and good long-term results in patients whose vessels are not otherwise graftable," says Thoralf M. Sundt III, M.D., an associate professor of cardiothoracic surgery. Sundt and colleagues reported their findings in a recent issue of Annals of Thoracic Surgery.

Blocked arteries

Grafts that bypass blocked arteries may themselves become blocked with plugs of calcified material. Such blockages prevent the heart from receiving sufficient blood, and patients may develop severe angina. But further bypass surgery is impossible if a patient1s vessels are too diffusely diseased to support additional grafts. "These patients survive, but they have terrible pain," Sundt says. "So what is the best way to treat them?" While testing a new method for providing blood flow to the heart called transmyocardial laser revascularization (TMR), the researchers encountered many patients who were ineligible for bypass surgery. "As we were evaluating those patients, we often wondered if they could have had coronary endarterectomy," Sundt says. "Our concern was that people who might benefit from that procedure might end up getting newer procedures whose benefits have not yet been determined." The newer procedures include TMR and angiogenic growth factor therapy, an experimental treatment that uses growth factors to promote new blood vessel formation. "TMR relieves angina, but we do not know whether it actually increases blood flow," Sundt says.

To determine how people with advanced heart disease fare after coronary endarterectomy, the researchers examined computerized medical records of 177 patients who underwent the procedure at Washington University Medical Center between Jan. 1, 1986, and March 30, 1997. They obtained follow-up data by phone and by mailing a questionnaire. The mean interval between the surgery and the follow-up was 56 months. The patients ranged in age from 39 to 83 years, with a mean age of 64 years. Sixty-eight percent of them were men. When compared with 6,919 patients who underwent coronary bypass grafting during the same period, the endarterectomy patients had a greater incidence of high cholesterol levels. Diabetes mellitus and a history of coronary artery bypass grafting also were more common. The data revealed that 11 patients died from heart attacks in the first 30 days after the endarterectomy, an operative mortality rate of 6 percent. This was slightly higher than the 4.5 percent rate for the bypass patients, but the difference between the two percentages was not statistically significant. The calculated 5-year survival rate was 75 percent or 76 percent, depending on which artery was cleaned out. At the follow-up, 75 percent of 117 survivors were free of angina, 6 percent had had angioplasty, and 3 percent had had more surgery. Only 4 percent had had a heart attack in the intervening years. "These complication and survival rates were quite satisfactory," Sundt says. "So we concluded that coronary endarterectomy can be performed with an acceptable risk and that it should be applied in a selective manner Ð to patients whose vessels are not otherwise graftable. It therefore should be considered as an alternative or supplement to the use of novel technologies such as TMR and angiogenic growth factor therapy."
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Note: For more information, refer to Sundt TM, Camillo CJ, Mendeloff EN, Barner HB, Gay WA., "Reappraisal of Coronary Endarterectomy for the Treatment of Diffuse Coronary Artery Disease," Annals of Thoracic Surgery, vol. 68, pp. 1272-1277, October 1999.

Washington University in St. Louis

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