Authors
Shevchenko Yu.L., Katkov A.A., Ermakov D.Yu., Ulbashev D.S., Vakhrameeva A.Yu.
St. George thoracic and cardiovascular surgery clinic Pirogov National Medical and Surgical Center, Moscow
Abstract
In recent decades, the number of patients with coronary artery disease and diffuse coronary artery disease has increased, the results of revascularization of which remain unsatisfactory, and the risk of repeated interventions and postoperative complications is high. In some cases, such patients are classified as inoperable, and drug therapy is ineffective for them. It is for such patients that the method of stimulation of extracardial neoangiogenesis has been developed and introduced into clinical practice, which allows increasing the effectiveness of surgical treatment. In our article, a comparative assessment of the results of surgery in patients with diffuse coronary lesion after various methods of myocardial revascularization was carried out.
Aim: to compare the efficacy and safety of standard surgical and endovascular correction of coronary artery lesions, as well as complex myocardial revascularization (bypass surgery and percutaneous coronary intervention, supplemented by the “YurLeon” technique) in patients with diffuse coronary atherosclerosis.
Materials and methods. The study included 133 patients with coronary artery disease and diffuse coronary artery disease who were treated at the St. George Clinic of Thoracic and Cardiovascular Surgery named after N.I. Pirogov NMHC from 2011 to 2024. I – patients who underwent coronary bypass surgery (n = 35); II – endovascular correction of coronary blood flow disorders (n = 33); III – patients who underwent coronary bypass surgery supplemented by stimulation of extracardial neoangiogenesis (n = 37); IV – patients to whom percutaneous coronary intervention was supplemented with a minimally invasive procedure “Yurleon” (n = 28). According to the clinical and angiographic characteristics, the patients did not differ statistically significantly from each other. Clinical data, echocardiography parameters, the degree of damage to the coronary bed, complications after surgery, cases of major adverse cardiovascular and cerebrovascular events (MACCE), and overall survival were evaluated.
Results. The average follow-up period was 41.8±25.9 months. The groups differed in the frequency of repeated endovascular revascularization (repeated coronary bypass surgery was not performed) (p = 0.013): in group I (34.3%) it was observed more often than in group III (13.5%) (p = 0.04); it was the highest in group II (42.4%) of patients, which is statistically significantly higher, than in IV (17.9%) (p = 0.041). The study showed that the number of MACCE cases was statistically significantly different in different patient groups. After complex revascularization, the number of such observations decreased compared to isolated CABG or PCI (p = 0.0004), in group II the indicator was the highest (84.8%). At the same time, there was a tendency to a higher survival rate of patients in groups III and IV.
Conclusion. Complex myocardial revascularization in patients with coronary artery disease and diffuse coronary artery disease is an effective and safe procedure. A new hybrid approach combining percutaneous coronary intervention under the control of intravascular research methods and minimally invasive implementation of the “YurLeon” technique makes it possible to expand the possibilities of treating patients who were previously considered inoperable.
Keywords: ischemic heart disease, diffuse coronary atherosclerosis, endovascular revascularization, coronary bypass surgery, complex revascularization, YurLeon technique.
References
1. Brown RA, Shantsila E, Varma C, Lip GY. Epidemiology and pathogenesis of diffuse obstructive coronary artery disease: the role of arterial stiffness, shear stress, monocyte subsets and circulating mircoparticles. Ann Med. 2016; 48(6): 444-455. doi: 10.1080/07853890.2016.1190861.
2. Kurbanov SK, Vlasova EE, Akchurin RS, et al. Hospital and annual results of coronary bypass surgery in diffuse coronary artery disease. Cardiological Bulletin. 2019; 14(1): 60-66. (In Russ.)
3. Shevchenko YuL, Borshchev GG. Extracardial revascularization of the myocardium in patients with coronary artery disease with diffuse lesions of the coronary bed. M.: Publishing House of NMHC named after N.I. Pirogov, 2022. (In Russ.)
4. McNeil M, Buth K, Brydie A, et al. The impact of diffuseness of coronary artery disease on the outcomes of patients undergoing primary and reoperative coronary artery bypass grafting. Eur J Cardiothorac Surg. 2007; 31(5): 827-33. doi: 10.1016/j.ejcts.2006.12.033.
5. Lozano I, Capin E, de la Hera JM, et al. Diffuse Coronary Artery Disease Not Amenable to Revascularization: Long-term Prognosis. Rev Esp Cardiol (Engl Ed). 2015; 68(7): 631-3. doi:10.1016/j.rec.2015.02.013.
6. Dourado LOC, Pereira AC, Poppi NT, et al. The Role of the Heart Team in Patients with Diffuse Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting. Thorac Cardiovasc Surg. 2021; 69(7): 584-591. doi: 10.1055/s-0040-1718936.
7. Dourado LOC, Bittencourt MS, Pereira AC, et al. Coronary Artery Bypass Surgery in Diffuse Advanced Coronary Artery Disease: 1-Year Clinical and Angiographic Results. Thorac Cardiovasc Surg. 2018; 66(6): 477-482. doi: 10.1055/s-0037-1601306.
8. Mizukami T, Sonck J, Sakai K, et al. Procedural Outcomes After Percutaneous Coronary Interventions in Focal and Diffuse Coronary Artery Disease. J Am Heart Assoc. 2022; 11(23): e026960. doi: 10.1161/JAHA.122.026960.
9. Akchurin RS, Shiryaev AA, Vasiliev VP, et al. Modern trends in coronary surgery. Pathology of blood circulation and cardiac surgery. 2017; 21(3S): 34-44. (In Russ.)
10. Bolivogi ZhM, Maksimkin DA, Faibushevich AG, et al. The possibilities of increasing the effectiveness of percutaneous coronary interventions in patients with ischemic heart disease with diffuse multivessel damage of the coronary bed. Creative cardiology. 2021; 15(4): 482-95. (In Russ.) doi: 10.24022/1997-3187-2021-15-4-482-495.
11. Shiryaev AA, Akchurin RS, Vasiliev VP, et al. Annual outcomes of coronary artery bypass grafting in patients with diffuse lesion of coronary arteries. Kardiologiya i Serdechno-Sosudistaya Khirurgiya. 2021; 14(5): 413‑419. (In Russ.) doi: 10.17116/kardio202114051413.
12. Heo W, Min HK, Kang DK, et al. Long Segmental Reconstruction of Diffusely Diseased Left Anterior Descending Coronary Artery Using Left Internal Thoracic Artery with Extensive Endarterectomy. Korean J Thorac Cardiovasc Surg. 2015; 48(4): 285-288. doi: 10.5090/kjtcs.2015.48.4.285.
13. Briones E, Lacalle JR, Marin-Leon I, et al. Transmyocardial laser revascularization versus medical therapy for refractory angina. Cochrane Database Syst Rev. 2015; 2015(2): CD003712. doi: 10.1002/14651858.CD003712.pub3.
14. Iwanski J, Knapp SM, Avery R, et al. Clinical outcomes meta-analysis: measuring subendocardial perfusion and efficacy of transmyocardial laser revascularization with nuclear imaging. J Cardiothorac Surg. 2017; 12(1): 37. doi: 10.1186/s13019-017-0602-8.
15. Tasse J, Arora R. Transmyocardial revascularization: peril and potential. J Cardiovasc Pharmacol Ther. 2007; 12(1): 44-53. doi: 10.1177/1074248406297640.
16. Ryzhman NN, Kravchuk VN, Knyazev EA, Khubulava GG, et al. The experience of using minimally invasive direct myocardial revascularization during coronary bypass surgery. Bulletin of the Russian Military Medical Academy. 2014; 1: 7-12. (In Russ.)
17. Babunashvili AM, Kartashov DS, Babokin VE, et al. The effectiveness of sirolimus-coated stents in the treatment of diffuse (long and very long) atherosclerotic lesions of the coronary arteries. Russian Journal of Cardiology. 2017; 8(148): 42-50. (In Russ.) doi: 10.15829/1560-4071-2017-8-42-50.
18. Meier P, Hemingway H, Lansky AJ, et al. The impact of the coronary collateral circulation on mortality: a meta-analysis. Eur Heart J. 2012; 33(5): 614-621. doi: 10.1093/eurheartj/ehr308.
19. Shevchenko YL, Borshchev GG, Ulbashev DS. Long-term results of coronary bypass surgery, supplemented by surgical stimulation of extracardial myocardial vascularization, in patients with diffuse coronary lesion. Complex problems of cardiovascular diseases. 2023; 12(1): 160-171. (In Russ.) doi: 10.17802/2306-1278-2023-12-1-160-171.
20. Shevchenko YuL, Borshchev GG, Ulbashev DS. Surgical technique of angiogenesis stimulation (extracardial myocardial revascularization) in patients with coronary artery disease. Cardiology and Cardiovascular Medicine. 2022; 6: 529-535. doi: 10.26502/fccm.92920295.
