الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Diffuse CAD can be defined as the presence of multiple
atherosclerotic lesions or long-segment stenosis in coronary territory.
Atheromatous plaques spread toward distal and retain a long segment of
coronary arteries which can occlude coronary lumen consecutive or
longitudinal and partial or complete.
A large number of simple stenoses in one or two coronary vessels
can be treated by PCI. Therefore, the number of high-risk patients and
patients presented with severe diffuse CAD referred for coronary artery
bypass grafting (CABG) has been relatively increasing. Use of left internal
thoracic artery (LITA) to bypass left anterior descending artery (LAD) is
associated with long term patency and event free survival. Here in, we
report a case of long segment revascularisation of a diffusely diseased left
anterior descending artery (LAD) using the left internal mammary artery
(LIMA) (3).
In CABG surgery, complete revascularization is one of the most
important factors that reduce long-term morbidity and mortality. However,
in cases of a diffusely diseased LAD, complete coronary revascularization
is not always possible because conventional CABG techniques involving
only the distal LAD and cannot provide sufficient blood supply to the side
branches, including the septal and diagonal branches.
The choice of a surgical procedure also depends on the nature of the
coronary artery, and multisegment plaques and healthy-area intervals
simplify complete coronary revascularization. On the other hand, a more
aggressive procedure should be preferred when no soft site can be found
for arteriotomy or there is an extensively diseased area that is not amenable
to grafting. The less invasive procedures are “don’t touch the plaque”
Summary
95
techniques (jumping grafts, sequential anastomosis, hybrid interventions).
Sometimes an aggressive diffuse atherosclerotic plaque formation needs to
be treated with “touch the plaque” methods (long segment anastomosis,
patch plasty and endarterectomy with long segment reconstruction if
opened and without long segment reconstruction if closed). In simple
forms, a limited long segment anastomosis of grafts eliminates the
occlusion of the limited atherosclerotic plaque where the whole length of
the plaque is opened and cross-covered by the graft.
Coronary artery reconstruction was defined as performing CABG
anastomosis when there were extensive atheromatous plaques downstream
from the first major proximal lesion to the distal part. The length of a long
segment anastomosis should be more than two cm. A long superficial
arteriotomy was made along the diseased LAD, and the length of incision
was decided at the operation, with or without endarterectomy. Then longsegmental
LAD reconstruction was performed by covering the arteriotomy
with LITA as an onlay graft or saphenous vein as the onlay patch.
The aim of this study is to assess the early and mid-term
postoperative outcomes of left anterior descending artery reconstruction
using left internal mammary artery onlay patch or venous patch in coronary
artery bypass grafting (CABG) operation.
This study is a prospective observational study and was carried on
forty (40) patients who are diagnosed to have extensive coronary artery
atherosclerosis and multiple segmental left anterior (LAD) descending
artery critical lesions. from April 2019 to April 2022. These patients
underwent elective coronary artery bypass grafting (CABG) with left
anterior descending (LAD) artery reconstruction.
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96
Inclusion criteria:
Patients have severe coronary artery atherosclerosis with diffuse
significant long lesion or multiple critical lesions in LAD artery
indicated for elective CABG either on pump or off pump.
LAD artery reconstruction more than 2 centimetres.
Exclusion criteria:
Concomitant other cardiac procedures (e.g. valves replacements).
Patients have severe left ventricular dysfunction (e.g. EF <35 %).
Emergency CABG.
Patients who will undergo coronary artery endarteectomy.
All patients will be subjected to:
1. Pre-operative data:
Full history taking: Personal history, present history, risk factors
analysis, complete past history and family history.
Full clinical examination: general and local examination.
Investigations :
D. Laboratory: Lipid profile and glycated hemoglobin (Hb A1 C).
E. Radiological: chest x-ray. Cardiac: (ECG), coronary
angiography and echocardiography (including ejection fraction
(EF) and left ventricular dimension).
2. Operative data:
Total operative time, cardiopulmonary bypass and cross clamp time
Types of CABG either on pump or off pump.
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Number and sites of grafts and length of construction (distal
anastomosis).
Types of LAD reconstruction either LIMA onlay patch or saphenous
vein patch and ntraoperative complication.
3. Postoperative data:
a. In hospital:
Duration of mechanical ventilation, ICU stay and duration of
hospital stay.
Needs for inotropic support including intra-aortic ballon
counterpulsation.
Total blood drainage.
Postoperative morbidities andmortality.
Postoperative investigation: ECG changes, cardiac enzymes.
b. Follow up (for six months post-operative): All patients will be
followed in outpatient clinic one week, one month and six months
postoperative. In each visits patients will be assessed for:
Complaints of recurrent chest pain, history of postoperative MI,
readmission to CCU, other morbidities and mortality.
Full clinical examination.
Investigation: ECG, echocardiography and multislice copmuted
tomography (MSCT) coronary angiography will done six months
postoperative to assess the patency of LAD reconstruction.
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98
The results of our present study can be summarized as follows:
The mean age of the patients was 59.07 years ± 8.79 SD (42–74
years). There were 33 were male (80%) and 7 were female (20%).
17 (42.5%) were smokers. 15 (37.5%) had obesity. 28 had
hypertension (HTN) (70%), 25 (62.5%) had dyslipidaemia, 30 (75%)
had diabetes mellitus, 24 (60%) had a history of a previous MI and 5
(12.5%) had PVD. Preoperative hemoglobin A1C levels were 7.5
mg/dL ± 1.2 (range 5.2 –10.2).
Preoperatively (CCSC) 1 (2.5%) was in CCSC I, 17 patients
(42.5%) were in CCSC II, 16 patients (40%) were in CCSC III
while 6 patients (15%) were in CCSC IV. The mean CCSC was 2.7
with ± 0.757 SD.
Regarding to the preoperative CA, 12 patients (30%) had LM
disease, 8 (20 %) had two vessels disease and 32 patients (80%) had
three vessels disease.
The mean preoperative EF was 54% ± 8.8, the mean preoperative
LVEDD was 5.35 cm. ± 0.66 and the mean preoperative LVESD
was 3.7 cm. ± 0.62.
The mean time of operation was 211.3 minutes ± 58.4. In those with
on pump, the mean cardiopulmonary bypass time was 90 minutes ±
40.5 and the mean cross clamp time was 55.57 minutes ± 28.13.
On pump CABG was performed in 20 patients 50% and off pump in
50%.
Mean number of anastomoses done per patient was 3± 0.933.
The mean length of the reconstructed patch was 4.34 cm ± 1.57
(range 3–10). The patch used for reconstruction of the LAD was the
LIMA in 33 patients (82.5%) and the GSV patch in 7 patients
(17.5%).
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The mean mechanical ventilation time was 7.3 hours ± 6.5. The
mean ICU stay was 2.45 days ± 1.218 and the LOS was 7.15 days ±
2.5.
The mean volumes of postoperative blood loss were 578.75 ± 278.9
ml (200 - 1300). Two patients (5%) required re-exploration for
excessive bleeding.
2 patients 5 % with postperative myocardial infarction. 5 patients
(12.5%) had low cardiac output syndrome, two of them (5%)
required an IABP.
Two patients (5%) developed transient postoperative AF. 2 patients
(5%) developed hospital acquired pneumonia. 1 patient (2.5%)
developed acute renal insult.
One patient (2.5%) developed cerbrovascular stroke postoperative.
One patient (2.5%) had sternal wound infection postoperative.
Follow up of patients at outpatients clinic shows, three patients
(7.5%) had typical chest pain post-operatively. One patient (2.5%)
had CCSC II and two patients (5%) were in (CCSC) III.
One patient (2.5%) required percutaneous coronary intervention with
stenting to LCX artery.
Two patients (5%) required CCU admission after discharge due to
late MI.
One (2.5%) case of mortality after 2 months of discharge of hospital
due to COVID 19 pneumonia infection.
The mean postoperative EF was 56% ± 6.9. The mean postoperative
LVEDD was 5.32 cm. ±0.51. The mean postoperative LVESD was
3.73 cm. ± 0.52.
Follow up multislice CT coronary angiograms where done in the
remaining of the thirty nine patients (97.5%) after six months
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postoperative. Analysis revealed a full patent reconstructed LAD
patch in 39 patients (97%).