Coronary Artery Surgery

Excerpt

Treating coronary artery disease (CAD) has been a published concern of the medical community since at least 1816 with Samuel Black’s autopsy correlations between coronary calcification and angina pectoris. Initial surgical treatments were adventurous, ranging from sympathectomy to reduce angina symptoms, thyroidectomy to reduce myocardial hormonal stimulation, internal mammary artery ligation to augment hypothetical collateral vessel flow, abrasion of the pericardium to induce neovascularization, and ligation of the coronary sinus venous outflow, but none of these achieved clear success or widespread use.

Three other early coronary artery surgical procedures achieved some prominence and are worth noting. The Beck II procedure after Johns Hopkins surgeon Claude Beck involved a staged conduit anastomosis between the aorta and the coronary sinus. The Vinberg procedure popularized by McGill surgeon Arthur Vinberg was the implantation of the internal mammary artery into the anterior left ventricular myocardium. Coronary endarterectomy (CE), first performed by William Longmire in 1958, is direct removal of atherosclerotic plaque from the coronary artery, similar to the procedure currently employed for carotid arteries.

Further development of coronary artery surgery is traced through Alexis Carrel’s pioneering work on arterial anastomosis culminating in the 1912 Nobel Prize and later collaboration with Charles Linberg on a model for a heart-lung machine in the 1930s. The maturation of cardiopulmonary bypass through the works of John Gibbon, John Kirklin, and others enabled a motionless, bloodless surgical field for the construction of reliable anastomoses, setting the stage for the explosive development of coronary artery bypass grafting (CABG) in the late 1950s and 1960s. Many CABG pioneers have staked claims to the development of the procedure, including Robert Goetz, Rene Favoloro, Vasilii Kolesov, Michael Debakey, and David Sabiston.

Coronary artery surgery in contemporary practice is mostly confined to coronary artery bypass grafting (CABG), although some groups are reexploring the use of coronary endarterectomy (CE). The procedural discussion of CABG is also covered elsewhere. This article will focus more on consensus CABG recommendations and outcomes. Traditionally, the category “coronary artery surgery” excludes catheter-based endoluminal percutaneous coronary interventions (PCI), as discussed elsewhere.

The category “coronary artery surgery” may encompass traumatic disease of the coronary vessels, whether iatrogenic, blunt, or penetrating traumatic, but these conditions are rare. Standard treatment consists of observation, catheter-based therapy, direct repair (i.e., sew the hole shut), or CABG. Management depends on patient stability and anatomy, the bypassing proximal lesions, while distal lesions may even be ligated if their contribution to overall myocardial perfusion is limited.