Endarterectomy of the left anterior descending coronary artery. 
Increasing numbers of patients with extensive coronary artery disease present for surgical revascularization.  Diffuse atherosclerosis of the anterior descending artery remains a significant challenge and endarterectomy may be required to increase graft outflow.  A surgeon may choose local endarterectomy or be accidentally forced into endarterectomy when attempting to split a lesion distal to a critical stenosis.  Distal traction endarterectomy may be performed through a medium sized arteriotomy and closed with a vein patch, to which an internal mammary artery (IMA) or saphenous vein graft is constructed.  More diffuse disease, or the breaking of an endarterectomy specimen, may require a direct vision total endarterectomy of the entire length of the left anterior descending coronary artery (LAD), which is then closed by a long vein patch.  The IMA is not usually grafted to such an extensive reconstruction.  There has not been an increase in perioperative risk from LAD endarterectomy when compared to patients undergoing coronary artery bypass grafting without endarterectomy.