CASE
A 58-year-old male patient with LAD diffuse patient had hyperlipidemia and hypertension. Preoperative angiography showed that he had triple-vessel disease with diffusely diseased LAD (Fig 1). In echocardiography (EKO), EF was detected as 60 and PAP 25 mmHg and 2 degrees of tricuspid insufficiency.
In this case report, we will present our LAD endarterectomy. Surgical technique: We performed standard general anesthesia, cardiopulmonary bypass procedure and moderate hypothermia after cold cardioplegic capture. Approximately 10 cm long endarterectomy was performed on LAD. It was for a dissector to develop in the plane between the media and atheroma. Mild traction was applied to separate the atherosclerotic plaque with the branches of the coronary artery, the distal and proximal part of the LAD. We were sure no plaque of LAD distal options. Then we applied the same procedure to the proximal part of the LAD. We observed that the proximal atherosclerotic plaque was removed completely. We also observed the rotation of bolus cardioplegia through retrograde cardioplegia. We used saphenous vein for LAD reconstruction (Figure 2). With the traditional cardiopulmonary bypass surgery, individual bypass was applied to the obtuse marginal artery (OM1) and the diagonal artery (D) using saphenous vein graft. LAD proximal antegrade flow and lumen mouth opening were satisfactory in LAD proximal.
We intended to use proximal part of the saphenous vein for proximal aortic anastomoses. After completion of bypasses and patch plasty procedure cross clamping was released allow the heart before beginning to beat. The patient was warmed up. After defibrillating the heart two times, normal sinusal rhythm restored. Immediately before beginning the proximal anastomosis and mean arterial pressure was 60 mmHg on pump. Also we observed the pulsation of the LAD saphenous vein. Then we measured the saphenous vein pressure. This pressure was equal to aortic pressure. We made proximal anastomosis for right coronary artery. After these procedures we terminated to bypass but we didn’t made the proximal anastomosis for LAD. We allowed the heart to beat. İt was observed that heart was contracting normally with a mean pressure 70 mmHg. Before protamine administration we compared the pressures between LAD saphenous vein and aorta. All of them we measured equal. Then we applied the bulldog clamp to saphenous vein just above the patch. After protamine administration we did not observe any problem on heart beating with clamp we continue the bleeding control the heart was functionally well. Thus we decided to tie down the saphenous vein. We made only patch plasty like a carotid endarterectomy.
Total cardiopulmonary bypass time was 100 minute and an aortic cross-clamp time of 57 minute.
The patient stayed in intensive care for 3 days. He was uneventful postoperative course. The patient was discharged on the seventh postoperative day.
It is recommended that the combination of postoperative antiplatelet and warfarin after coronary endarterectomy should be given for several months (3). As thrombogenicity increases due to endothelial damage after coronary endarterectomy, we start routine anticoagulants and antiplatelets unless there is significant hemorrhage in the early postoperative hours. Postoperative follow up 12 years. This patient followed up coronary angiography was made 10 years after the operation (Fig 3). According to 10 years angiography result LAD patch plasty was working relatively good. Patient did not have any complaints. We made coronary angiography 12 years after the operation and observed that our patch plasty was occluded but patient have still class II symptoms. He is normal in daily activity now with and EF value 40%.