Surgical Treatment in Diffuse Coronary Artery Disease

Diffuse coronary artery atherosclerosis can be defined as “consecutive or longitudinal” and “complete or partial” obstruction in coronary vessels. Most of the patients with dia‐ betes, hyperlipidemia, chronic renal insufficiency, connective tissue disease, and multistented coronary arteries have diffuse atherosclerotic lesions in the coronary territory. Viable large myocardium without necrosis is the only coronary bypass indication in these patients, because it is very difficult to find any healthy area for anastomosis. This type of coronary occlusion frequently stimulates the formation of collateral vessels that protect against extensive myocardial ischemia. The choice of a surgical method also depends on the nature of the coronary artery, and multisegment plaques and healthy-area intervals simplify complete revascularization. On the other hand, a more aggressive treatment mo‐ dality should be preferred when no soft site can be identified for arteriotomy or there is an extensively diseased area that is not amenable to grafting. The less invasive techniques are “don’t touch the plaque” techniques (jumping multi-bypass, sequential bypass, hy‐ brid interventions). Sometimes an aggressive diffuse plaque formation needs to be treat‐ ed with “touch the plaque” techniques (long-segment anastomosis, patch-plasty, endarterectomy ± patch-plasty). In simple forms, a limited long-segment anastomosis of conduits eliminates the occlusion of the limited atherosclerotic plaque where the whole lesion is opened and cross-covered by the graft. In the accelerated form of coronary arte‐ riosclerosis, the atherosclerotic plaque appears widespread and the full-length lumen of the coronary artery can get very narrow or occluded totally. The long-segment lesion is usually calcified and it inhibits any kind of stitching; however, the plaque can be separat‐ ed easily from the arterial wall in order to create an appropriate lumen in the total oc‐ cluded coronary artery. Because the aggressive endarterectomy increases the operation risk, the arteriotomy should be extended until the normal lumen with normal intima in the distal segment of the coronary artery. In general, severity and distribution of coronary arteriosclerosis tend to increase with time but the rate of increase is highly variable and difficult to predict. Although diffuse atherosclerosis is severe enough, it is uncommon to render any patient unsuitable for surgery.