Mid-Term Outcome of Surgical Coronary Ostial Plasty: Our Experience

Abstract

The conventional coronary artery bypass procedure that uses venous or arterial conduit for isolated critical stenosis of the left main coronary artery (LMCA) restores a less physiological perfusion of the myocardium and uses an appreciable length of bypass material. Coronary ostial plasty has been described as an alternative surgical technique in proximal obstructive coronary artery disease without calcifications. Here we report 23 patients (15 males and 8 females aged 37-78 years; mean age 57 years) who underwent surgical ostial plasty. Ostial reconstruction with fresh pericardial patch was performed in all patients: 15 patients with LMCA stenosis, 6 patients with right coronary (RC) ostial stenosis, and 2 patients with both RC artery and LMCA stenosis. In seven cases, coronary artery bypass grafting was added for contralateral distal stenosis with a total of five arterial conduits and six venous grafts. One patient died; the ostial plasty and grafts were patent at necropsy. Thallium-201 myocardial scintigraphy under stress at 30 days to 6 months after operation demonstrated good myocardial perfusion in 21 of 22 patients. Coronary angiography at follow-up (49 +/- 8 months) demonstrated good surgical ostial plasty results in 21 of 22 patients and good coronary flow in 19 of 22 patients; angiographic study at mid-term follow-up revealed only one failure of the surgical ostial plasty technique associated with venous graft obstruction. In 2 other patients CABG failure due to venous graft obstruction (1 patient) or distal stenotic lesions of the left coronary artery (1 patient) was noted. The overall successful outcome of the surgical ostial plasty was 22 of 23. We believe that surgical angioplasty of the coronary ostia may be used in the presence of proximal noncalcified obstructive lesions as an alternative technique, which offers a more physiological revascularization; it also spares grafting material and allows subsequent percutaneous transluminal angioplasty or coronary artery bypass surgery.

The feasibility of surgical patch osteoplasty in isolated left main coronary stenosis.

“…Because better myocardial protection and cardiopulmonary bypass techniques have developed, Hitchcock and coworkers [6] recreated and adjusted the angioplasty of the LMCA procedure by introducing the posterior approach with good outcomes. Dion and colleagues [3] improved the procedure and published the largest series of 47 patients, and an expanding number of surgeons have been stimulated to adopt surgical angioplasty again using several surgical techniques, approaches and patch material, with variable surgical outcomes [11][12][13][14]. Since then, coronary osteoplasty was classified as an alternative surgical procedure to conventional CABG in patients with proximal obstructive non-calcified coronary artery disease.…”

“…However, its lack of fibrinolytic characteristics may theoretically enhance calcification and future restenosis. Malyshev and colleagues found that the restenosis percentage was 3.4% when the autologous saphenous vein was used for surgical osteoplasty and 4.9% when autologous pericardium was used as patch material [13]. The right mammary artery can be used as a patch, but essentially abolishes future utilization of this conduit; additionally, the size of the right mammary artery patch does not permit for creating a funnel-shaped ostium as preferred by Dion and colleagues [16].…”