The Right Gastroepiploic Artery Graft for Coronary Artery Bypass Grafting: A 30-Year Experience

Minimally invasive direct coronary artery bypass to the left anterior descending artery using right gastroepiploic artery graft for a redo case with poor conduits

A 64-year-old Thai woman underwent coronary artery bypass grafting (CABG) using saphenous vein grafts (SVG) for completely occluded left anterior descending artery (LAD) and mitral valve replacement with mechanical valve about a year ago. She presented with unstable angina. Three-dimensional computed tomography angiography (3DCTA) showed occlusion of all the grafts. The left subclavian artery had 99% stenosis. The patient underwent redo CABG via a minimally invasive direct approach. The chest was entered through the left fifth intercostal space. The right gastroepiploic artery (RGEA) and a small length of SVG were harvested. The RGEA was extended using the SVG with an end-to-end anastomosis and used to graft the LAD without cardiopulmonary bypass. The patient's postoperative course was uneventful. Postoperative 3DCTA revealed patent RGEA-SVG graft. Minimally invasive direct coronary artery bypass to LAD with RGEA is a useful alternative approach for redo CABG in patients with not much choice of conduits.

Right Coronary Artery Chronic Total Occlusion After Bypass Grafting Successfully Treated Using Reverse Controlled Antegrade and Retrograde Subintimal Tracking (CART) Technique via the Gastroepiploic Artery: A Case Report

Patient: Male, 63-year-old

Final Diagnosis: Chronic total coronary artery occlusion

Symptoms: Angina pectoris

Medication:—

Clinical Procedure: Percutaneous coronary intervention

Specialty: Cardiology

Graft Patency of a Second Conduit for Coronary Artery Bypass Surgery: A Network Meta-Analysis of Randomized Controlled Trials

It has been well documented that the use of the left internal thoracic artery (LITA) to graft the left anterior descending (LAD) artery has a significant benefit in coronary artery bypass graft (CABG) surgery. However, what graft is the best as a second conduit to complement LITA-LAD anastomosis remains uncertain. We thus conducted a network meta-analysis of RCTs to compare graft patency of the radial artery (RA), the right internal thoracic artery (RITA), the right gastroepiploic artery (RGEA), conventional saphenous vein (C-SVG), and no-touch saphenous vein (NT-SVG) as a second conduit in CABG. MEDLINE and EMBASE were searched through August 31, 2020 to identify randomized controlled trials (RCTs) that investigated graft patency of a second conduit in CABG. From each study, we extracted the incidence rate ratios of the outcome. A total of 13 RCTs were identified, including 3728 patients and 2773 angiographic results. The graft failure rates were significantly lower in NT-SVG and RA compared to C-SVG and RGEA. There was no significant difference among the other comparisons. A sensitivity analysis restricting trials with ≥3 years angiographic follow-up time showed the graft failure rates were significantly lower in NT-SVG and RA compared to C-SVG and RGEA, and a sensitivity analysis restricting trials with ≥5 years angiographic follow-up time showed the graft failure rates were significantly lower in NT-SVG and RA compared to C-SVG. In a network meta-analysis of the updated outcomes from RCTs, NT-SVG and RA have better graft patency compared to C-SVG and RGEA.

Application of tissue-engineered interventions for coronary artery bypass grafts

Coronary artery bypass graft is one of the extensively conducted procedures to release occlusion in the coronary vessel. Various biological grafts are used for this purpose, superiorly, saphenous vein graft, if unavailable, other vessels in the body, with likewise characteristics are exploited for the purpose. The choice of graft is yet under discovery that could impeccably meet all the requirements. Variation in perioperative and postoperative results have given uneven clinical inferences of these conduits. Alternatively, tissue-engineering is also being applied in this area for clinical improvements. This review underlines some of the commonly used grafts for coronary artery bypass graft and advancements in tissue engineering for this purpose.

Right internal thoracic or radial artery as the second arterial conduit for coronary artery bypass surgery

PURPOSE OF REVIEW

To summarize the available evidence on the use of the right internal thoracic artery (RITA) and the radial artery as the second arterial graft in coronary artery bypass surgery.

RECENT FINDINGS

The current data support the equipoise of the two conduits in terms of clinical and angiographic outcomes. Both RITA and radial artery have better patency than saphenous vein grafts. The use of the RITA carries an increased risk of deep sternal wound infection (DSWI) if the artery is harvested as pedicle. Bilateral internal thoracic artery grafting is more technically demanding than radial artery use and there is a volume-outcome relationship in terms of mortality and incidence of DSWI. The radial artery is preferable over RITA in right-sided or distal circumflex artery targets with high-degree stenosis and in patients at higher risk for DSWI, whereas it is not recommended to graft vessels with moderate stenosis and in cases of insufficient collateralization from the ulnar artery or previous transradial procedures.

SUMMARY

The patency rate and clinical outcomes of radial artery and RITA are similar. The use of one or the other should be based on a careful evaluation of the patient's coronary anatomy and comorbidities, the conduit availability and the surgeon's and center's experience.

State-of-the-Art Coronary Artery Bypass Grafting: Patient Selection, Graft Selection, and Optimizing Outcomes

Despite the progressive expansion of clinical indications for percutaneous coronary intervention and the increasingly high risk profile of referred patients, coronary artery bypass grafting (CABG) remains the mainstay in multivessel disease, providing good long-term outcomes with low complication rates. Multiple arterial grafting, especially if associated with anaortic techniques, might provide the best longer-term outcomes. A surgical approach individualized to the patients' clinical and anatomic characteristics, and surgeon and team experience, are key to excellent outcomes. Current evidence regarding patient selection, indications, graft selection, and potential strategies to optimize outcomes in patients treated with CABG is summarized.

Fifty years of coronary artery bypass grafting

Coronary artery bypass grafting (CABG) remains the most common cardiac surgery performed today worldwide. The history of this procedure can be traced back for more than 100 years, and its development has been touched by several pioneers in the field of cardiac surgery, who have contributed with both their successes and failures. With ever increasing follow up and number of patients treated, thinking regarding optimal CABG technique evolves continually. This article reviews the history of CABG from its early experimental work to recent technological advances.