Coronary artery bypass surgery with stent removal and coronary endarterectomy using a saphenous vein graft as an adventitial substitute (“flooring”) for reconstruction of the left anterior descending artery: A case report

Background Coronary endarterectomy with stent removal followed by arterial reconstruction is a surgical option for complex in-stent restenosis (ISR). However, this strategy generally assumes preservation of the coronary adventitia, and management of adventitial loss during stent removal has rarely been described. Case summary A 67-year-old man on hemodialysis presented with exertional angina one year after percutaneous coronary intervention to the left anterior descending artery (LAD). Coronary angiography demonstrated severe ISR of the LAD with complex multivessel disease, and urgent off-pump coronary artery bypass grafting was performed. During coronary endarterectomy with stent removal, dense adhesion between the stent and vessel wall caused unavoidable loss of the coronary adventitia over a 10-mm segment. A longitudinally opened saphenous vein graft was used as an adventitial substitute (“flooring”) to reconstruct the LAD, followed by bypass using an in situ left internal thoracic artery with an onlay patch technique. The postoperative course was uneventful, and follow-up angiography confirmed excellent graft patency. The patient remained asymptomatic at 3-month follow-up. Discussion This case highlights a salvage technique for unexpected adventitial loss during coronary stent removal. The use of an SVG as an adventitial substitute—the “flooring” concept—combined with arterial onlay reconstruction may represent a feasible option in selected patients with complex ISR.