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A Case of Diffuse Three-Vessel Coronary Artery Disease With Triple Coronary Endarterectomy in a Patient Undergoing Coronary Artery Bypass Grafting

Tuesday, January 29, 2019

Jakob H, Mourad F, Lubarski J, Schlosser T, Shehada S-E. A Case of Diffuse Three-Vessel Coronary Artery Disease With Triple Coronary Endarterectomy in a Patient Undergoing Coronary Artery Bypass Grafting. January 2019. doi:10.25373/ctsnet.7594841.

Patients with diffuse coronary artery disease are usually judged not to be candidates for percutaneous or surgical intervention. In this video, the authors present a triple coronary endarterectomy (CEA) in a patient with severe coronary artery disease using a closed-traction technique (traction-CEA).

Patient Demographics

A 68-year-old man presented with stable angina pectoris and dyspnea on exertion. Medical history revealed arterial hypertension and hyperlipidemia. Neither smoking, diabetes, nor positive family history were reported for coronary disease. Cardiac computed tomography (CT) demonstrated an Agatston score of 450 (AU) and subsequent coronary angiography showed diffuse three-vessel coronary disease. The patient presented in CCS class II and had a SYNTAX score of 44.

Operative Course

Coronary artery bypass target vessels were the right coronary artery (RCA), the left anterior descending artery (LAD), and the obtuse marginal artery (OM2). All three vessels were sub-totally occluded (<1.25 mm). Traction-CEA was performed to the RCA, LAD, and OM2 to achieve complete myocardial revascularization. Flushing the coronary vessel with cardioplegia and proximal/distal vessel massaging were both done to get rid of residual debris after CEA in order to avoid early failure. Intraoperative transit time flow measurement reported high flows and a low pulsatility index (PI).


Postoperative course was uneventful. Control CT angiography demonstrated patent bypass grafts and adequate peripheral run off. The patient was discharged from the hospital after eight days. According to the authors’ policy, the patient received dual antiplatelet therapy for six months. A twelve month follow-up phone call confirmed full rehabilitation.


Patients with diffuse coronary artery disease are high-risk candidates for surgical revascularization. CEA offers a good option for such patients but requires adequate experience of the operating surgeon. Traction-CEA is the authors’ preferred method in comparison to open endarterectomy. Dual antiplatelet therapy seems to be supportive to achieve long-term patency of the endarterectomized vessels. Thus, complete revascularization with a satisfactory long-term prognosis can be achieved.


I congratulate with the authors for this excellent result. However, I wouldn’t encourage CEA since it is widely recognized that the procedure leads to significant post-operative complications and carries out a relatively high mortality. Your technique is certainly interesting but I am not really compelled that removing a few debris is going to make a difference in the contest of the massive inflammatory and thrombogenic intra-coronary response. This without considering the significant high-risk of bleeding connected with the aggressive early post-operative anticoagulation. I am surprised by the numbers presented in your last slide with 302 patients followed up over 10 years because over my 15 years experience, through several centers and including my personal series, the average incidence of CEA was in the order of 1-2% of all the CABG cases.

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