Endarterectomy-Supported Arterial Revascularization

Offering hope to patients with severe coronary disease

Innovations in Cardiovascular Medicine & Surgery - Summer 2018

 Joseph F. Sabik, MD

Today’s candidates for coronary artery bypass grafting (CABG) often present with severe cardiac artery disease (CAD) as well as other co-morbidities, challenging surgeons to rethink the best methods for revascularization to improve cardiac output, reduce symptoms and positively impact patients’ quality of life.

“As minimally invasive cardiac therapies have progressed, patients who have less complex coronary artery disease — or lesions that are isolated — are frequently treated by interventional cardiologists,” says Joseph Sabik, MD, Chair, Department of Surgery, UH Cleveland Medical Center, Surgeon-in-Chief and Vice President of Surgical Operations, University Hospitals; Professor of Surgery, Case Western Reserve University School of Medicine. “Often, patients who need coronary artery bypass surgery have more advanced disease by the time they come to us.”

Heart disease remains the leading cause of mortality and morbidity in the United States, accounting for one in four deaths (1). Yet options for treatment are hampered by the reality that patients are presenting with increased medical complexity, including diabetes, obesity or poor hemodynamics. Additionally, many patients have had prior revascularization procedures or their coronary disease has progressed.

“Instead of a single blockage, patients often have diffusely diseased arteries with multiple obstructions,” Dr. Sabik says. How can physicians improve revascularization outcomes for this underserved population?

At University Hospitals Harrington Heart & Vascular Institute, cardiac surgeons and interventional cardiologists work together to master new therapies for complex coronary artery disease and offer patients every opportunity to get better. That includes offering endarterectomy, a highly specialized adjunctive technique, for patients who might otherwise be considered inappropriate candidates for CABG because of higher procedural risk or the potential that traditional surgical bypass would not be effective.

ADVANCEMENTS IN ENDARTERECTOMY PROCEDURES

Dr. Sabik describes endarterectomy as a procedure that is both old and new.

“Endarterectomy involves making a long incision in the artery so that we are able to visualize the entire length of the blockage, perform atherectomy to remove the plaque and bypass to the now clean artery,” he says, adding that while the technique has been around, recent modifications have improved upon the procedure as a surgical option. In fact, several studies have shown endarterectomy to be a safe and feasible technique for patients with diffuse arterial disease (2).

The first two endarterectomies in human subjects were documented in JAMA (The Journal of the American Medical Association) in 1957 (3). Originally, the process was blind, with only a small opening placed in the artery to remove plaque through endarterial curettage. However, advancements in protecting the heart during surgery, including innovations in cardiopulmonary bypass technology, are compensating for the added procedure times of 20 to 30 minutes that make open endarterectomy visualization possible.

Next-generation anti-platelet agents also play an important role in the safety and efficacy of endarterectomy. During the procedure, removal of the atheromatous plaque within the artery leaves a raw surface because of disruption to the endothelium and the exposed area can be prone to thrombosis. Anti-platelet medications are prescribed post-operatively to mitigate this risk.

“The goal of endarterectomy is to increase the pool of patients we are able to help through complex surgical revascularization,” Dr. Sabik says. “We’ve developed this solution to take care of more people and offer them hope. This is something we’ve been doing over the past several years with very good outcomes.”

For more information or to refer a patient, call (216) 844-3800 or email HVInnovations@UHhospitals.org.

REFERENCES

1. Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2015 on CDC WONDER Online Database, released December 2016. Data are from the Multiple Cause of Death Files, 1999-2015, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. 
2. Myers, PO, Tabata, M, Shekar, PS, Couper, GS, Khalpey, ZI, Aranki, SF. Extensive endarterectomy and reconstruction of the left anterior descending artery: Early and late outcomes. The Journal of Thoracic and Cardiovascular Surgery. 2012, 143(6):1336-1340.
3. Bailey CP, May A, Lemmon WM. Survival after coronary endarterectomy in man. JAMA. 1957; 164(6):641-646.