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%.