What are the guidelines for patients undergoing Coronary Artery Bypass Grafting (CABG) with endarterectomy?

Guidelines for Coronary Artery Bypass Grafting (CABG) with Endarterectomy

Coronary endarterectomy (CE) combined with CABG is a valuable surgical approach for patients with diffuse coronary artery disease, though it requires careful perioperative management to optimize outcomes and reduce complications.

Indications for CABG with Endarterectomy

• CE is indicated as an adjunctive procedure to CABG in patients with diffusely diseased coronary arteries that are totally or subtotally occluded 1
• Most commonly performed on:
  • Left anterior descending (LAD) artery (41.4%)
  • Right coronary artery (RCA) (43.9%)
  • Left circumflex artery (6.8%)
  • Diagonal branches/intermedius ramidus (8.0%) 2

Preoperative Management

Antiplatelet Therapy

• Aspirin (100-325 mg daily) should be administered preoperatively 3
• Discontinue clopidogrel and ticagrelor for at least 5 days before surgery 3
• Discontinue prasugrel for at least 7 days before surgery 3
• For urgent CABG, discontinue clopidogrel and ticagrelor for at least 24 hours 3
• Short-acting glycoprotein IIb/IIIa inhibitors should be discontinued:
  • Eptifibatide/tirofiban: at least 2-4 hours before surgery
  • Abciximab: at least 12 hours before surgery 3

Preoperative Assessment

• Carotid artery duplex scanning is reasonable in high-risk patients (age >65 years, left main coronary stenosis, peripheral artery disease, history of cerebrovascular disease, hypertension, smoking, diabetes) 3
• Multidisciplinary team approach is recommended for patients with clinically significant carotid artery disease 3

Intraoperative Management

Myocardial Protection

• Blood cardioplegia is recommended for patients with chronically dysfunctional left ventricle 3
• Consider prophylactic intra-aortic balloon pump (IABP) for patients with ongoing myocardial ischemia and/or subnormal cardiac index 3

Surgical Technique

• Left internal mammary artery (LIMA) should be used to bypass the LAD whenever possible 4
• Routine epiaortic ultrasound scanning is reasonable to evaluate the presence, location, and severity of aortic plaque 3
• Aggressive blood conservation techniques are indicated to limit hemodilutional anemia and transfusion requirements 3

Postoperative Management

Antiplatelet and Anticoagulation Therapy

• Aspirin (100-325 mg daily) should be initiated within 6 hours postoperatively and continued indefinitely 3, 4
• Consider dual antiplatelet therapy with aspirin plus P2Y12 inhibitor for up to 12 months in selected patients 4

Medication Management

• Beta blockers should be administered for at least 24 hours before CABG and reinstituted as soon as possible postoperatively 3
• Continue beta blockers indefinitely unless contraindicated 4
• High-intensity statin therapy is indicated for all patients post-CABG with target LDL-C <100 mg/dL and at least 30% reduction from baseline 4
• ACE inhibitors or ARBs are recommended, especially for patients with left ventricular dysfunction, hypertension, diabetes, or chronic kidney disease 4

Glucose Management

• Continuous intravenous insulin should be used to achieve and maintain early postoperative blood glucose ≤180 mg/dL while avoiding hypoglycemia 3, 4

Monitoring

• Continuous electrocardiographic monitoring for arrhythmias should be performed for at least 48 hours 3, 4
• Consider measurement of cardiac biomarkers in the first 24 hours after CABG 3

Risk Factors and Outcomes

Risk Factors for Adverse Outcomes

• Age ≥65 years (HR 2.12)
• Left main disease (HR 2.56)
• Mitral regurgitation (≥mild) (HR 1.91)
• Left anterior descending endarterectomy (HR 1.69) 2

Expected Outcomes

• Graft patency rates:
  • Saphenous vein grafts: 80-90% at 1 year, approximately 50% at 10 years
  • Internal mammary artery grafts: 90-95% patency at 10-15 years 4
• CE + CABG can provide satisfactory short-term results with acceptable mortality and morbidity 5
• Long-term survival rates after CE + CABG: approximately 83% at 10 years 6

Complications and Management

Potential Complications

• Perioperative myocardial infarction (higher risk with CE)
• Stroke
• Bleeding requiring transfusion
• Deep sternal wound infection

Infection Prevention

• Preoperative antibiotics should be administered to all patients 3
• First- or second-generation cephalosporin is recommended for prophylaxis in patients without methicillin-resistant Staphylococcus aureus (MRSA) colonization 3
• Vancomycin alone or in combination with other antibiotics is recommended for prophylaxis in patients with proven or suspected MRSA colonization 3

Long-term Follow-up

• Regular follow-up visits to assess blood pressure control, lipid levels, glycemic control, medication adherence, and symptoms of recurrent ischemia 4
• Cardiac rehabilitation is strongly recommended for all patients after CABG 4
• All smokers should receive in-hospital educational counseling and smoking cessation therapy 3, 4
• Screen for depression, which is common after CABG and affects adherence 4

Special Considerations

• CE on the LAD appears to confer a high probability of freedom from late cardiac death 6
• Patients older than 70 years and those with chronic obstructive pulmonary disease have increased risk of late mortality after CE + CABG 6
• Consider off-pump CABG to reduce perioperative bleeding and allogeneic blood transfusion 3

By following these guidelines, surgeons can optimize outcomes for patients requiring the more complex CABG with endarterectomy procedure, providing revascularization options for those with diffuse coronary disease who might otherwise have limited treatment options.