ANGIOSCOPIC EVALUATION OF INTRAVASCULAR MORPHOLOGY AFTER CORONARY ENDARTERECTOMY

Coronary endarterectomy in diffuse coronary disease is attended by an increased incidence of perioperative myocardial infarction and vein graft occlusion, which have been partially attributed to the presence of occlusive or thrombogenic intraluminal flaps in the main vessel or its smaller branches. To define the nature and incidence of these features we studied 15 endarterectomized right coronary arteries in 15 patients (12 men, 3 women; age, 55 +/- 7 years [mean +/- standard deviation]) undergoing a coronary operation for multivessel disease. After endarterectomy and distal graft anastomosis, angioscopy was performed using a 1.8-mm Olympus angioscope during graft perfusion with crystalloid solution. The endarterectomy cores were 66 +/- 30 mm in length with 11 major bifurcations and two trifurcations providing 30 major endpoints. At 22 of 30 major endpoints the distal end of the core was smooth and tapered. There were 17 minor side-branch endpoints. Angioscopy revealed the presence of wispish intraluminal fronds and medial bruising in all (100%) arteries. Twenty-nine of the 30 intraluminal endpoints could be visualized. Major intraluminal flaps were seen at the eight nontapered endpoints and six of the 21 smooth tapered endpoints that were visualized. Fifteen minor side branches could be identified angioscopically: a flap was seen at only one side-branch origin. The average examination time was 3.2 +/- 1.1 minutes (7.7% +/- 2.7% of cross-clamp time), and examination required 200 to 250 mL of perfusate. This technique enables immediate and accurate postinterventional assessment of intravascular morphology with minimal prolongation of ischemic time and has shown that small side branches are not compromised by endarterectomy. However, both nontapered and, to a lesser extent, tapered major endpoints on an endarterectomy core may be associated with major intraluminal flaps or arterial dissection. The relationship between intraluminal morphology and patency remains to be assessed.