[HSF] LAD ENDARTERECTOMY

Nasser F. Abou'Seada nfaabouseada at gmail.com
Sat Jan 13 12:03:00 EST 2007 

Very well said Ani  

NFA

> From: Ani Anyanwu
> Anecdotal responses are all well and good, but from a scientific
standpoint,
> nobody has answered Tohru's questions.
> 
> 1. Do you really follow all patients postoperatively in long term?
> 2. Do you have confirmation study (MDCT and/or angiogram) in early and
long
> term follow up?
> 3. What evidence do you have for the safety of such procedure?
> 
> Those who claim such success with the procedure should study the patients
> and publish the data for all to see. For now I suspect your answer to all
> three questions is no. That one sees some successful angiograms or sees
> patient alive 20 years later does not on its own mean the procedure is
> beneficial. In researching this subject I sought an answer to Tohru's
> question from the literature and could not find a single study that could
> answer these questions.
> 
> Biologically an endarterectomy should not have the same result as standard
> CABG - there are key differences such as the presence on an unendothelized
> raw surface which is thrombogenic, possibility of emboli, possibility of
> intimal dissection, etc - so it is not surprising that some may be
skeptical
> of its outcomes. If the outcomes were truly no different as some opinions
or
> literature suggest, we would not be discussing it in the first place. To
> 'boast' of doing these off-pump, is indeed a recognition that they are
> riskier (in some form or another) than conventional CAB. The level of this
> risk is open to dispute but it exists by definition.
> 
> The onus is on us to provide the data. We cannot have it both ways. We
> castigate our colleagues from the cash lab for providing a simple
mechanical
> solution to a complex problem and claiming success without evaluating
their
> results or looking at the data. Yet we are doing exactly the same -
opening
> a completely occluded vessel and expecting all to believe that because the
> vessel is open it must be a good thing. Like for angioplasty, that it can
be
> done does not necessarily mean it should be done.
> 
> I do not have any strong views either way - Indeed I am as skeptical of
Hal
> of Tohru's 99.9% off-pump rate which suggests one use of CBP in 800 cases
-
> I suspect that if one looks at the data - as will be also be the case for
> those who claim minimal risk with endarterectomy - one will find that
> occasional patient who was forgotten. When Kocher thought 100 years ago
that
> his thyroidectomy patients never got myxoedema, he recalled all this
> patients and found over half had it - as he put it he had " prided himself
> with successful surgery but turned his patients into cretins giving them a
> life not worth living". Even the greatest of surgeons get their
> recollections wrong. There is currently no evidence favoring either
approach
> (radical endarterectomy or conservative grafting) - the onus is on those
who
> undertake these procedures to study the patients and provide us with data.
> 
> Ani
>   ----- Original Message -----
>   From: Tohru Asai<mailto:toruasai at belle.shiga-med.ac.jp>
>   To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>   Sent: Saturday, January 13, 2007 2:24 AM
>   Subject: Re: [HSF] LAD ENDARTERECTOMY
> 
> 
>   I personally do not perform endarterectomy with OPCAB. Although my
> isolated
>   coronary bypass had been performed 99.9% off-pump in past 7 years (over
> 800
>   cases).
> 
>   Reason why I avoid endarterectomy is simple. No proven safety to avoid
> acute
>   , subacute and longterm thrombosis. If you lose LIMA to LAD grafting
> during
>   followup, the patient will suffer fatal MI and/or CHF without question.
In
>   addition, hypercoagulability certainly exits in OPCAB, compared with
> on-pump
>   cases,such procedure carries even higher risks.Don Ross (hello!) gave a
>   thoughtful comments on this. Very impressed. Wise Tea's comment are
>   represent silent majority's opinion, I guess.
> 
>   Instead, what I do is aggressive multi-arterial sequential grafting to
> each
>   branches. Arterial grafts especially IMA stay open in midterm, even in 1
> mm
>   coronary arterial branches in angiograms.
> 
>   So, I think that the question is not whether you can or cannot do such a
>   thing, but whether you should or not.
> 
>   I want to ask those who perform endarterectomy with OPCAB following
>   questions.
>   1. Do you really follow all patients postoperatively in long term?
>   2. Do you have confirmation study (MDCT and/or angiogram) in early and
> long
>   term follow up?
>   3. What evidence do you have for the safety of such procedure?
> 
>   Once coronary endarterectomy was abandoned in history because of
miserable
>   outcome due to sudden occlusion, then coronary bypass became evidence
> based
>   treatment for longevity and secondary prevention for MI. (which PCI has
>   never achieved, and probably will not.)Current medications certainly
quite
>   different from ones in old days, but history may repeat itself.
> 
>   Resected specimen and early postop angio were really impressive, but so
>   what? Do you envy masturbational interventionalists?
>   Any comments welcome.
>   --
>   Tohru Asai
>   Shiga University of Medical Science
>   Otsu, Japan
> 
> 
> 
> 
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