Early and midterm results of stent endarterectomy for left anterior descending coronary artery ⇜full metal jacket”

Abstract

Objective: Modern coronary interventional practice can result in coronary vessels that are totally stented. The term “full metal jacket” has been coined to refer to vessels that have an overlapping stent in series along the whole length of the vessel. This poses a serious challenge to surgical revascularization, particularly when a left internal thoracic artery (LITA) to the left anterior descending (LAD) needs to be undertaken. We evaluated the early and midterm results of on-pump coronary artery bypass grafting (CABG) following “stent endarterectomy” for the LAD with LITA to LAD grafting. Methods: During October 2017 to September 2020, 21 patients presented with multi-vessel disease and a totally occluded LAD with a stent full metal jacket. No distal target for LITA grafting was available, despite a viable myocardial territory. The LAD was endarterectomised, removing the column of totally occluded stents with the medial wall of the vessel, leaving the proximal stent in place to avoid competitive flow. Long length anastomosis was then undertaken with the LITA graft. Postoperatively, patients were followed up clinically and by coronary computed tomography (CT) angiography at 6- and 18-month intervals. All patients were discharged on a combination of aspirin and warfarin for three months and then aspirin and clopidogrel for the rest of the first year and then aspirin alone for life. Results: Patients had a mean age of 58.07 ± 2.06 yr. Sixteen (76.2%) were males, 13 (61.9%) patients were diabetics, 18 (85.7%) were hypertensive, 15 (71.4%) were dyslipidemic, six (28.6%) were obese, 11 (52.4%) were smokers, and five (23.8%) had positive family history of ischemic heart disease (IHD). The number of grafts per patient ranged 3-5, with a mean cross-clamp time of 64.71± 8.84 min. There were no postoperative deaths nor MI clinically, by electrocardiogram (ECG) criteria nor by troponin or CK-MB. In-hospital complications included one (4.8%) patient who