Direct and indirect coronary surgery.

DRAMATIC developments have marked the progress of operative technics devised to treat coronary artery disease since the first selective cinearteriographic study was Selective coronary cineangiography can precisely demonstrate the degree of obstruction , the exact location and distribution, and also the presence of collateral circulation within a lumen diameter of 100 g or larger. The data obtained with this method are the basis on which the surgeon selects not only the patient for whom surgical revascularization is appropriate, but also the specific surgical technic. Another advantage of coronary cine-angiography is that it is the basis for evaluating the results of revascularization surgery, even though there is some correlation between the clinical postoperative evaluation and the angiographic findings. Surgical treatment of coronary artery disease can be classified into three different groups: (a) direct myocardial revasculariza-tion, (b) indirect myocardial revasculariza-tion, and (c) resection of scar tissue or ventricular aneurysm on the left ventricle Direct Myocardial Revascularization Early in 1962, the Cleveland Clinic team attempted to perform true endarterectomies. Nevertheless, the mortality rate was extremely high, due mainly to dissection of the distal portion of the coronary circulation or occlu-sion of important side branches, and the procedure was abandoned. The next method used was the pericardial patch-graft reconstruction. A longitudinal incision was made at the site of the obstruction precisely located by reviewing carefully the preoperative coronary cineangiography. A patch was sewn with fine 6-0 silk, generally with running sutures at both sides and interrupted sutures at the proximal and distal ends. There was low operative mortality among patients who underwent operation on the right coronary artery. On the other hand, among patients who submitted to operation on the left coronary artery, mainly because of the anatomic position of the artery, the mortality was extremely high (65%). Of the 163 patients who were operated upon, approximately 60% benefited and showed no obstruction anywhere in the reconstruction. In about 20% of cases the results were poor because of undue diminution of the lumen, and approximately 20% of the patches were closed. In May, 1967, the saphenous vein graft technic in direct coronary artery reconstruction was introduced at the Cleveland Clinic .2 3 Careful analysis of patients who previously underwent pericardial patch-graft reconstruction led us to consider the possibility of utilizing the saphenous vein graft technic, predicated on its successful use for several years in peripheral vascular and renal artery reconstruction. Initially we started with …