Technical aspects and late functional results of gastroepiploic bypass grafting (400 cases)

Does the Addition of a Gastroepiploic Artery to Bilateral Internal Thoracic Artery Improve Survival?

It is unclear whether the additional conduit to supplement bilateral internal thoracic arteries (BITA) influences the patient outcome in coronary surgery. This retrospective study compared long-term survival of patients undergoing left-sided BITA grafting in which the third conduit to the right coronary system (RCA) was either vein graft (SVG) or gastroepiploic artery (GEA). From 1989 to 2014, 1432 consecutive patients underwent left-sided revascularization with BITA associated with SVG (n = 599) or GEA (n = 833) to RCA. Propensity score was calculated by logistic regression model and patients were matched 1 to 1 leading to 2 groups of 320 matched patients. The primary end point was the overall mortality from any cause. GEA was used in significantly lower risk patients. The 30-day mortality was 1.6% without influence of the graft configuration. Postoperative follow-up was 13.6 ± 6.6 years and was 94% complete. The significant difference in patients' survival observed at 20 years in favor of GEA in unmatched groups (48 ± 4% vs 33 ± 6%, P < 0.001) was not confirmed in matched groups (41 ± 7% vs 36 ± 7%, P = 0.112). In multivariable Cox model analysis, the conduit used to RCA did not influence the long-term survival in matched groups, like no other graft configuration or operative parameter. Only complete revascularization remained predictor of survival (P = 0.016), with age (P < 0.0001), diabetes status (P = 0.007), and left ventricle ejection fraction (P < 0.0001). Long-term survival in patients undergoing BITA grafting is not affected by using GEA as third arterial conduit in alternative to SVG. Further studies are necessary to assess its impact on long-term cardiac events.

Redo-Coronary Artery Bypass due to Progression of the Celiac Axis Stenosis

We report a redo coronary artery bypass grafting (CABG) in a 55-year-old man. Angina recurred 7 years after the initial surgery. Coronary angiography showed all patent grafts except a faint visualization of the in situ right gastroepiploic artery (RGEA) graft, which was anastomosed to the posterior descending coronary artery, associated with celiac axis stenosis. Redo-CABG was performed at postoperative 10 years because of aggravated angina and decreased perfusion of the inferior wall in the myocardial single photon emission computed tomography. The saphenous vein graft was interposed between the 2 in situ grafts used previously; the right internal thoracic artery and RGEA grafts. Angina was relieved and myocardial perfusion was improved.

En-bloc free gastroepiploic artery graft provides a good long-term patency rate

For coronary artery bypass grafting, the use of free gastroepiploic artery is unpopular because of its tendency to vasospasm. We assessed the en-bloc free gastroepiploic artery graft, which has the gastroepiploic vein anastomosed to the right atrial appendage to prevent graft spasm, and compared it to the skeletonized free gastroepiploic artery graft. A retrospective review was conducted in 57 patients who received en-bloc grafts and 29 who had skeletonized grafts. Kaplan-Meier analysis demonstrated the superiority of the en-bloc free gastroepiploic artery graft with an 80-month patency rate of 96.6% compared to 66.7% with skeletonized grafts. We selected 13 cases from each group, using propensity-score matching, and compared the long-term patency rates. Propensity-score matched analysis showed 80-month patency rates of 100% for en-bloc grafts and 60% for skeletonized grafts. Coronary artery bypass using free gastroepiploic artery grafts with venous drainage seems to provide good long-term results.

Effects of ultrasonic skeletonization of the gastroepiploic artery on endothelial nitric oxide production

OBJECTIVE

: The right gastroepiploic artery (GEA) is a reliable conduit for coronary artery bypass grafting. Recently, ultrasonic skeletonization in graft harvesting has attracted attention as an alternative technique to increase the length and caliber size of grafts. The influence of GEA skeletonization using an ultrasonically activated device with that using an electrosurgical unit was compared from the viewpoint of production of nitric oxide (NO).

METHODS

: Fourteen pigs were used in this study. The GEA were harvested using an ultrasonically activated device (group ultrasonically activated device [USAD], n = 7) or electrocautery (group E, n = 7). Blood sampling was performed at the following three times from the distal end of the GEA: (1) preskeletonization, (2) pedicle, and (3) postskeletonization. Plasma NOx (NO metabolites) levels were measured by chemiluminescent assay. Moreover, in excised specimens, the expression of nitric oxide synthase was examined immunohistologically.

RESULTS

: In group USAD, the preskeletonization basal level of plasma NOx in GEA was 25.7 ± 10.9 μmol/L, which then increased to 26.9 ± 10.5 μmol/L (pedicle) and 32.2 ± 12.1 μmol/L (postskeletonization). In group E, the preskeletonization basal plasma NOx level in GEA was 28.9 ± 11.4 μmol/L, which changed to 27.5 ± 8.9 μmol/L (pedicle) and 21.8 ± 8.3 μmol/L (postskeletonization). The results of multivariate analysis indicated that the patterns of changes in plasma NOx level were significantly different in both groups (P = 0.024). In group USAD, post hoc multiple comparison tests revealed a significant difference between preskeletonization and postskeletonization (P = 0.037).

CONCLUSIONS

: Ultrasonically skeletonized GEA showed increased effective graft length, higher free flow capacity, and increased endothelial NO production than that prepared using an electrosurgical unit.

The right gastroepiploic artery in coronary artery bypass grafting

The right gastroepiploic artery (RGEA) has been used as a conduit in coronary artery bypass grafting. Although some reports presenting good results justify its use in clinical settings, there is still much concern about using the RGEA in bypass surgery. The RGEA demonstrates different behaviors from the internal thoracic artery (ITA) in bypass surgery due to its histological characteristics and anatomical difference, which might contribute to the long-term outcome. Now that left ITA (LITA) to left anterior descending artery (LAD) is the gold standard, other grafts are expected to cover the rest of the coronary arteries. It should be elucidated how we can use other grafts and what we can expect from them. RGEA, as an arterial graft, can be used as an in situ graft or a free graft. The RGEA is mainly used to graft to the right coronary artery (RCA) because of its anatomical position, and its patency is not inferior to that of the saphenous vein (SVG). The RGEA can cover the lateral walls when its length is long enough or by making a composite graft with other grafts. However, when used to graft to the LAD, its mid-term patency is not favorable.

Long-term follow-up of coronary artery bypass grafting in three-vessel disease using exclusively pedicled bilateral internal thoracic and right gastroepiploic arteries

BACKGROUND

Considerable data now exist that show that coronary artery bypass grafting with bilateral internal thoracic artery (ITA) grafts produce better outcomes than the use of a single ITA graft. The benefit of a third arterial graft has been less well established. Therefore this article describes the survival and cardiac-related event-free survival in patients having bilateral ITA and gastroepiploic artery (GEA) grafting for 3-vessel disease.

METHODS

From November 1992 to May 2002, 201 patients (mean age 53 +/- 7 years) presented with 3-vessel disease and received exclusively bilateral internal thoracic (ITAs) and right gastroepiploic (GEA) arteries as pedicled grafts for coronary artery bypass procedure. Twenty-seven (13%) patients were not elective, 10 (5%) were reoperations, 115 (57%) had one or more myocardial infarction, 21 (10%) had diabetes. In total 733 anastomoses were constructed (3.7/patient), with sequential grafting in 124 (62%) patients. The clinical follow-up was complete. The patients were followed for up to 10 years (mean 6.4 +/- 2.7 years).

RESULTS

Ten-year actuarial survival (including in-hospital death) was 87%. The actuarial freedom from angina pectoris, after hospital discharge, was 97% and 86% at 5 and 10 years respectively. None of the patients needed a repeat surgical revascularization after leaving the hospital, whereas 9 (5%) patients underwent a percutaneous transluminal coronary angioplasty. At 5 years 86% and at 10 years 69% of the patients remained free of any cardiac-related event.

CONCLUSIONS

The results of this study clearly indicate that the exclusive and extensive use of pedicled bilateral ITA and GEA in coronary bypass grafting provides excellent 10-year patient survival and functional improvement in terms of freedom from return of angina pectoris and, more impressive, freedom from any cardiac-related event. Our findings clearly corroborate the concomitant use of bilateral ITA and GEA grafts in selected patients with 3-vessel disease.

Coronary revascularization in the 21st century. Emphasis on contributions by Japanese surgeons

The first three decades of coronary artery surgery have provided the foundation for the next century of this evolution. It is apparent that a multitude of events including the development of cardioplegia, improving surgical instrumentation, technological advances including endoscopic approaches and computer assisted robotics and biologic discoveries such as the role of the endothelium have provided the underpinnings for improved surgical outcomes. However, the single most important determinant of late results is the type of bypass conduit used for grafting. Thus, use of the left internal thoracic artery (ITA) grafted to the left anterior descending coronary is a more important determinant of survival than is any other factor (progression of coronary artery disease, increased age, poor left ventricular function, diabetes, female gender and off-pump operations). Use of two ITAs provides further benefit and it is likely that three or more arterial conduits will be shown to be advantageous in this regard in due time. Japanese cardiothoracic surgeons have made significant contributions to the continuing evolution of coronary bypass surgery and particularly to the advance of arterial conduits. This report will address those contributions to this evolution.

Limited flow capacity of the right gastroepiploic artery graft: postoperative echocardiographic and angiographic evaluation

BACKGROUND

The flow capacity of the right gastroepiploic artery graft has not been clarified.

METHODS

Angiographic and echocardiographic studies were conducted in 30 patients who had undergone coronary artery bypass grafting using both the internal thoracic and right gastroepiploic arteries. The luminal diameter of the arterial grafts was measured from the postoperative angiograms. The adequacy of the myocardial blood supply from the arterial grafts was evaluated by dobutamine stress echocardiography.

RESULTS

With echocardiography, 14 patients exhibited an ischemic response in the gastroepiploic artery grafted region, whereas no patients exhibited an ischemic response in the internal thoracic artery grafted area. The luminal diameter of the gastroepiploic artery and a younger age were correlated with the ischemic response observed in the dobutamine stress echocardiography. A luminal diameter of the gastroepiploic artery of greater than 2.6 mm had the highest sensitivity and specificity for a nonischemic change.

CONCLUSIONS

To generate the maximal flow reserve, the luminal diameter of the gastroepiploic artery when used as a graft should be sufficiently large enough, nearly 3 mm at the anastomosis.

Noninvasive assessment of coronary flow reserve in the right gastroepiploic artery graft

BACKGROUND

To investigate the functional capacity of the right gastroepiploic artery graft (GEA) and its ability to adapt to provide adequate flow at peak myocardial demand, we investigated the feasibility of determining coronary flow reserve (CFR) provided by this vessel using transabdominal color Doppler echocardiography and the correlation between this noninvasive determination of flow reserve and nuclear stress scintigraphy.

METHODS

In 40 selected patients, who underwent complete arterial myocardial revascularization using the GEA and the internal thoracic arteries (ITAs), CFR of the GEA was measured at maximum coronary hyperemia induced by intravenous adenosine infusion, 7 months (range 3 to 20) after surgery. In the same period, in 31 of this group of patients, exercise thallium scintigraphy was performed.

RESULTS

We succeeded in measuring CFR in 37 of 40 patients with values ranging from 1.1 to 3.6 with an average of 2.1 +/- 0.7. During adenosine infusion, mean velocity in the GEA significantly increased from 48 +/- 20 to 89 +/- 41 cm/sec (p < 0.001), mean arterial blood pressure significantly decreased from 96 +/- 11 to 87 +/- 11 mm Hg (p < 0.001), and heart rate significantly increased from 74 +/- 11 to 87 +/- 15 beats/min (p < 0.001). In 8 of these 37 patients, the nuclear exercise test was positive (compatible with reversible ischemia in the distribution area of the GEA). Average CFR in these 8 patients with positive nuclear stress test was 1.46 +/- 0.28 versus 2.27 +/- 0.70 in those patients with a negative test (p < 0.001).

CONCLUSIONS

Noninvasive determination of CFR of GEAs is feasible, using transabdominal Doppler echocardiography. The present study shows that coronary vasodilator reserve and autoregulation is maintained in myocardium supplied by the GEA and that the CFR has a significant correlation with the results of noninvasive nuclear exercise testing. Therefore, noninvasive determination of CFR by transabdominal Doppler echocardiography might be a valuable contribution to functional assessment of GEAs.

Successful percutaneous stenting of a right gastroepiploic coronary bypass graft using monorail delivery system: a case report

The right gastroepiploic artery (RGEA) is being successfully used as an arterial conduit in a selected group of patients undergoing coronary artery bypass graft surgery. However, myocardial ischemia may result due to spasm, occlusion, and stenosis of this graft. The anastamosis site at distal right coronary artery (RCA) or posterior descending artery (PDA) is the most common location for stenosis of an in situ gastroepiploic coronary bypass graft. Balloon angioplasty of such stenoses has been reported with optimal short-term results. Stent deployment would decrease the restenosis rate, so that repeat procedures could be minimized for these technically challenging lesions. We describe a case of successful deployment of a stent with monorail delivery system at the anastamotic site stenosis of an in situ gastroepiploic right coronary artery bypass graft. This percutaneous coronary intervention could prevent redo coronary artery bypass graft surgery. Cathet. Cardiovasc. Intervent. 49:197-199, 2000.

Initial experience with MIDCAB grafting using the gastroepiploic artery

BACKGROUND

Minimally invasive direct coronary artery bypass grafting with the gastroepiploic artery can be used in primary operations and reoperations to revascularize the inferior or anterior surface of the heart.

METHODS

Patients who had symptomatic coronary artery disease limited to a single coronary distribution were selected. Coronary targets were grafted with the pedicled gastroepiploic artery through a small midline epigastric incision. Patients were followed with scheduled outpatient clinic visits, Doppler examination, and selective recatheterization.

RESULTS

Between May 1995 and November 1997, 74 patients underwent gastroepiploic artery minimally invasive direct coronary artery bypass grafting; 33 (45%) had a primary operation and 41 (55%), a reoperation. Grafting was performed to the distal right coronary artery (n = 38), the posterior descending artery (n = 28), or the distal left anterior descending coronary artery (n = 8). There were six deaths (8%) within 30 days after operation. Twenty patients (28%) underwent recatheterization; there were two graft occlusions, two graft stenoses, and five anastomotic stenoses. Of 60 patients seen 2 or more weeks after operation, 53 (88%) had resolution of anginal symptoms at a mean follow-up of 10.9 months (range, 0 to 30 months).

CONCLUSIONS

Inferior minimally invasive direct coronary artery bypass grafting with the gastroepiploic artery avoids the risks of repeat sternotomy, aortic manipulation, and cardiopulmonary bypass. Patency rates, however, were lower than expected, and there is significant morbidity and mortality associated with high-risk patients undergoing the procedure. Continued follow-up is essential to evaluate long-term graft patency and patient survival.

Noninvasive assessment of right gastroepiploic artery graft patency using transcutaneous color Doppler echocardiography

BACKGROUND

Because the right gastroepiploic artery graft (GEA), when routed antegastrically, is situated just behind the abdominal wall, we investigated the possibility of evaluating graft patency and flow characteristics using transabdominal color Doppler echocardiography.

METHODS

The right GEA graft was evaluated in 71 patients who underwent complete arterial revascularization, 4 months (range, 2 to 17 months) postoperatively. Selective angiography of the right GEA was performed in the patients in whom the graft could not be visualized using color Doppler echocardiography.

RESULTS

Flow in the right GEA graft was detected in 65 (91.5%) of 71 patients using color Doppler echocardiography. In all visualized right GEAs, a biphasic flow pattern was observed, with higher peak velocity during systole. Mean (+/- standard deviation) peak systolic velocity was 76+/-16 cm/s. Mean (+/- standard deviation) velocity was 41+/-14 cm/s. Selective angiography of the right GEA in 5 patients in whom the graft could not be visualized using echocardiography showed four patent and functional grafts and one graft that was open but not functional ("slender sign"). One patient died before angiography could be performed. The sensitivity of noninvasive ultrasound assessment of the patency of the right GEA graft was 94% (65 of 69 patients). In this group of patients, an overall right GEA graft patency rate of 97% (69 of 71 patients) was found at mean follow-up of 4 months (range, 2 to 17 months).

CONCLUSIONS

The right GEA graft is an adequate coronary artery graft with a good short-term patency rate, and transcutaneous color Doppler echocardiography is a useful tool for evaluating its patency and flow characteristics. Selective angiography of the right GEA can be avoided in most cases and is indicated only when the graft cannot be detected using Doppler echocardiography.

Intraoperative flow measurements in gastroepiploic grafts using pulsed Doppler

OBJECTIVE

The patency of a pedicled right gastroepiploic artery (RGEA) graft can be compromised by intraoperative twists, kinks or spasms. Therefore, a systematic flow assessment was made in RGEA grafts and was compared with similar measurements made in other types of bypass conduits.

METHODS

Intraoperative pulsed Doppler flowmeter measurements obtained in a series of 556 consecutive patients undergoing at least one coronary bypass grafting onto the right coronary system were studied. Eighty-five RGEA grafts were compared with 1427 bypass grafts implanted in the same group of patients and consisted of the following conduits: 442 left internal mammary (LIMA), 149 right internal mammary (RIMA), 831 greater saphenous vein (GSV) and five inferior epigastric (EPIG) grafts. Sequential grafts were excluded from the analysis.

RESULTS

Flow measurements and Doppler waveforms were abnormal and required graft repositioning, and the addition of a distal graft or intragraft papaverine injection (only in GSVs) in 29 cases (2.0% of all grafts). These graft corrections were necessary in 5.9% RGEAs, 3.4% LIMAs, 2.0% RIMAs, and 0.7% GSVs (P < 0.001). The relative risk for graft correction was eight times higher for RGEAs than for GSVs (P = 0.002). Flow increased from 8 +/- 2 to 54 +/- 5 ml/min (P < 0.0001). Flow data were significantly influenced by the type of run-off bed (P < 0.001), the measurements obtained in grafts implanted onto the right coronary artery and the left anterior descending artery being superior. Flows in RGEAs, however, were comparable with values obtained in other grafts implanted onto the same recipient coronary artery.

CONCLUSIONS

A significantly higher incidence of graft malpositioning caused inadequate flows in RGEAs. However, normal flow values could be restored simply by assigning a better graft orientation under pulsed Doppler flowmeter control. Overall flow capacity of the RGEA did not differ from values obtained in other arterial and venous grafts implanted onto the same recipient arteries.

Case of successful percutaneous stenting of an in situ gastroepiploic-coronary bypass graft

The in situ or free gastroepiploic artery (GEA) is being used as an arterial conduit for coronary artery bypass surgery (CABG). The recent rapid improvements in stent manufacture, particularly their profile and flexibility, and related equipment, have helped reduce complications of coronary angioplasty. We describe one case of successful stenting of an in situ GEA-posterior descending artery graft. Stenting of an in situ GEA graft may avoid an incomplete result of angioplasty with possible restenosis or the need for multiple surgical revascularization. The use of stents in GEA grafts with 6 Fr soft guiding catheters can be encouraged.

[A case report of gastric perforation after coronary artery bypass grafting with right gastroepiploic artery]

A 71-year-old man, who had received coronary angioplasty to right coronary artery 1 year before, was admitted because of unstable angina. An urgent CABG was performed using the left internal thoracic artery and the right gastroepiploic artery. Coronary anastomosis was performed under ventricular fibrillation due to porcelain aorta. Seven days after surgery, abdominal pain was suddenly experienced. A chest X-P showed subphrenic free air. So an emergent laparotomy was performed, and a 2 x 2 cm gastric perforation was found on the anterior wall of the greater gastric curvature. Partial gastrectomy was performed. However, he unfortunately died on the 58th postoperative day for multiple organ failure. Pathological examination of the excised gastric wall revealed ischemic change, not ulcer. This gastric perforation was possibly caused by ischemia after harvesting the right gastroepiploic artery.

Evaluation in vivo of the endothelial function of the native gastroepiploic artery

The endothelial function of a coronary bypass graft is an important aspect, contributing not only to its patency but to its functional performance. To evaluate this aspect in vivo, we studied 16 patients who underwent selective catheterization of the native gastroepiploic artery (GEA). Quantitative angiography of the GEA was performed at baseline, after 2 minutes' infusion of acetylcholine in three ascending doses, and after 2 mg isosorbide dinitrate injection directly into the GEA. Mean GEA diameter was 2.02 +/- 0.38 mm at baseline. We observed dose-dependent vasodilation during acetylcholine infusion: The mean diameter increased slightly to 2.11 +/- 0.32 mm (+6%, not significant) with the second dosage and, more significantly, with the highest dosage, to 2.32 +/- 0.33 mm (+18%, p < 0.001). More important vasodilation was observed after administration of nitrates (+36%, p < 0.001). We found no difference between patients with and without coronary artery disease and no relationship with risk factors for atherosclerosis. A positive correlation was seen between the vasodilation observed after nitrate administration and the highest dose of acetylcholine (r = 0.728, p = 0.002). In conclusion, the GEA demonstrates a notable vasodilatory response to nitrates (non-endothelium-dependent) and a dose-related dilator response to acetylcholine, reflecting preserved endothelial function. This sensitivity should affect favorably the hemodynamic performance of grafts performed with GEA, as well as these grafts' long-term patency rate.

Ischemic gastric ulcer after coronary bypass using the right gastroepiploic artery

The gastroepiploic artery has been widely used for complete arterial myocardial revascularization of young patients. Gastric complications related to the harvesting of this artery are exceptional. We describe here a case of ischemic gastric ulcer due to the use of a gastroepiploic artery in a patient with severe celiac trunk disease. The patient was cured by angioplasty completed by a stenting procedure.