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Ann Thorac Surg 1996;62:1342-1346
© 1996 The Society of Thoracic Surgeons

Original Article: Cardiovascular

Flow Competition of the Right Gastroepiploic Artery Graft in Coronary Revascularization

Naomichi Uchida, MD, Yasushi Kawaue, MD

Department of Cardiovascular Surgery, Hiroshima General Hospital, Hiroshima, Japan

Accepted for publication May 23, 1996.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. In recent years, there has been a substantial increase in the use of arterial grafts for coronary revascularization. Arterial grafts are more vulnerable than saphenous vein grafts to hypoperfusion syndrome. The purpose of this study was to examine flow competition between the right gastroepiploic artery and native coronary arteries in patients undergoing coronary artery bypass grafting.

Methods. Between December 1989 and July 1995, 182 patients underwent coronary artery bypass grafting using the right gastroepiploic artery. Coronary flow patterns were examined in 172 patients by postoperative angiography. Flow patterns were divided into four types: right gastroepiploic artery dependent (n = 128), balanced (n = 24), native dependent (n = 18), or occluded (n = 2).

Results. All grafts with an old myocardial infarction (n = 75) and 94% of grafts with 99% stenosis (n = 16) were classified in the right gastroepiploic artery–dependent category. In patients with angina pectoris, flow patterns were more frequently classified as right gastroepiploic artery dependent, with increasingly severe native coronary artery proximal stenoses (99% > 90% > 75%) or with stenoses more distal in location.

Conclusions. Flow competition depended on three factors: the viability of the revascularized area, the degree of proximal stenosis, and the location of stenosis. Right gastroepiploic artery grafts should be selected for coronary artery bypass grafting with consideration of these three factors.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
In recent years, the trend in coronary artery bypass grafting (CABG) has been toward the routine use of multiple arterial grafting techniques because of superior patency rates compared with venous grafts [1, 2]. The right gastroepiploic artery (RGEA) has been used with satisfactory midterm results and is a reliable arterial graft for CABG [3–6] after the internal thoracic artery (ITA). However, flow competition between the native coronary artery and the RGEA has been reported in some studies [7, 8]. Therefore, we evaluated flow competition between the RGEA and the native coronary artery using early postoperative angiography to determine the indications for the use of RGEA grafts in CABG.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patient Population
From December 1989 to July 1995, 182 patients underwent CABG with an RGEA graft. There were 108 male patients and 74 female patients, with a mean age of 67.2 years (range, 42 to 83 years). Preoperative patient characteristics included diabetes in 53 (29%), hypercholesterolemia in 86 (47%), unstable angina in 30 (16%), emergent operation in 27 (15%), and acute myocardial infarction in 7 (4%). One hundred eighteen patients (64.8%) had a history of a previous myocardial infarction, and the preoperative left ventricular ejection fraction was less than 0.40 in 19 patients (10.4%).

Surgical Technique
We used RGEA grafts with a diameter greater than 1.67 mm (5 F) as determined by preoperative angiography. The standard median sternotomy incision was extended 5 to 10 cm caudally. After one or both ITAs were harvested, the peritoneal cavity was entered. The RGEA was dissected with the placement of two surgical absorbable clips (Absolok; Ethicon Inc, Somerville, NJ) on side branches to the stomach and omentum. The artery was then dissected along the distal half of the greater curvature of the stomach and to the pylorus. After systemic heparin treatment, the distal portion of the RGEA graft was divided, and dilute papaverine was injected gently into the graft. Before cardiopulmonary bypass, each RGEA graft was determined to have flow greater than 40 mL/min. The course of the RGEA to the pericardial cavity was anterior to the pylorus and left lobe of the liver. The coronary anastomoses were performed with running 8-0 polypropylene sutures. The pedicle was fixed to the epicardium with a 5-0 polypropylene suture to avoid kinking of the graft.

Angiographic Evaluation
Angiography of the RGEA graft was performed preoperatively in 88 patients. The preoperative diameter of the RGEA was measured at the midpoint of the greater curvature of the stomach in comparison with the catheter. Elective follow-up angiography was performed 3 to 5 weeks postoperatively in 172 patients (94.5%) with a 5 F catheter (S5F-38-70-SEO; Clinical Supply Inc, Gifu, Japan) through the femoral approach. The contrast catheters were advanced into the gastroduodenal artery.

We analyzed flow patterns between the RGEA and the native coronary artery in the RGEA grafts. Flow patterns were divided into four categories, as follows (Figs 1–3GoGoGo): (1) RGEA-dependent: the entire native coronary artery was perfused by the RGEA graft; (2) balanced: the distal coronary artery to the RGEA anastomosis could be well visualized by both native and RGEA injections; (3) native-dependent: the RGEA was patent, but the entire native coronary artery was perfused by the native coronary artery itself; and (4) occluded: the RGEA was occluded.



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  		Fig 1. . Right gastroepiploic artery–dependent pattern: The entire native coronary artery is perfused from the right gastroepiploic artery graft. (Left) Right coronary arterial angiography. (Right) Right gastroepiploic artery graft angiography. (RCA = right coronary artery; RPD = right posterior descending artery.)

 


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  		Fig 2. . Balanced pattern: The distal coronary artery to the anastomosis of the right gastroepiploic artery (RGEA) can be well visualized during both native and right gastroepiploic artery injection. (Left) Right coronary arterial angiography. (Right) Right gastroepiploic artery graft angiography. (Abbreviations are as in Figure 1.)

 


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  		Fig 3. . Native-dependent pattern: The right gastroepiploic artery (RGEA) is patent, but the entire native coronary artery is perfused by the native coronary artery itself. (RCA = right coronary artery.)

 
We classified 172 RGEA grafts into the four flow patterns on the basis of the postoperative angiographic study. Those flow patterns were analyzed in regard to three factors: (1) the degree of coronary stenosis, (2) the myocardial viability (the presence of an old myocardial infarction [OMI] or angina pectoris), and (3) the location of the proximal stenosis.

The postoperative diameter of the RGEA graft was measured 1 cm proximal to the anastomosis in 88 patients who had undergone preoperative angiography.

The diameter of the RGEA graft was analyzed statistically by Fisher's exact test. The relations among the viability of the revascularized area, the degree of proximal stenosis, and the location of stenosis were assessed by {chi}2 test. A p value of less than 0.05 was considered statistically significant.


   Results
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 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
A total of 502 anastomoses were performed with 480 arterial grafts (182 RGEAs, 181 left ITAs, 85 right ITAs, and 32 inferior epigastric arteries) and six saphenous vein grafts. The pattern of graft placement is shown in Table 1Go. The average number of grafts was 2.7 per patient, and the average number of distal anastomoses was 2.8 per patient.


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  		Table 1. . Patterns of Graft Placement in 182 Patients Undergoing Coronary Artery Bypass Grafting
 
One hundred eighty-one RGEA grafts (94.5%) were used as in situ grafts, and one RGEA graft was used as a free graft. Nineteen RGEA grafts (10.4%) were anastomosed to the left anterior descending artery, 30 (16.5%) to the left circumflex artery, and 138 (76.4%) to the right coronary artery (RCA). Sequential RGEA grafting was performed in 5 patients, with three grafts anastomosed to the RCA-left circumflex artery and two to the RCA-RCA (Table 1Go).

Clinical Outcome
Four patients (2.7%) died within 30 days postoperatively: 2 died of low output syndrome, 1 of sudden cardiac arrest, and 1 of sudden ventricular fibrillation. Three patients (1.6%) had perioperative myocardial infarctions. There were no hospital deaths. Five patients died during long-term follow-up from extracardiac causes: gastric cancer (2), cerebral infarction (2), and lung cancer (1). One hundred fifty-five patients (95%) reported the absence of angina. Repeat CABG was performed in 2 patients, and interventional angioplasty was performed in 2.

Angiographic Evaluation
The early patency rate of the RGEA was 98.8% (170 of 172). Flow patterns were divided into four categories: RGEA dependent (n = 128), balanced (n = 24), native dependent (n = 18), and occluded (n = 2). The preoperative diameter of the RGEA graft was measured in 88 patients. The mean diameter was 2.28 ± 0.34 mm. The preoperative diameters of the RGEA grafts were not significantly different among the postoperative flow patterns: RGEA dependent (n = 61, 2.25 ± 0.36 mm), balanced (n = 16, 2.31 ± 0.38 mm), and native dependent (n = 11, 2.30 ± 0.21 mm). However, the postoperative diameters of the RGEA grafts were significantly different among the postoperative flow patterns: RGEA dependent (2.32 ± 0.38 mm), balanced (1.93 ± 0.43 mm), and native dependent (0.86 ± 0.62 mm) (Table 2Go).


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  		Table 2. . Diameter of Right Gastroepiploic Artery (RGEA) Grafts as Determined by Preoperative and Postoperative Angiography
 
Seventy-five RGEA grafts were anastomosed to the OMI lesion and 97 to the angina pectoris lesion. All 75 grafts with an OMI lesion and the majority of grafts (15 of 16) with a 99% stenosis were classified into an RGEA-dependent pattern. On the other hand, 61% (31 of 51) of grafts with a 90% stenosis and 23% (seven of 30) with a 75% stenosis had an RGEA-dependent pattern. The number of grafts with an RGEA-dependent pattern increased significantly as the degree of proximal stenosis became more severe (100% > 99% > 90% > 75%) (Table 3Go).


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  		Table 3. . Flow Patterns According to the Degree of Native Coronary Stenosis
 
In terms of the relation between the location of the RCA stenosis and the flow pattern, no grafts with a 75% native coronary artery stenosis located between the proximal and distal RCA demonstrated an RGEA-dependent pattern, but 78% of grafts (seven of nine) with a 75% native coronary stenosis located at the right posterior descending artery (RPD) or the atrioventricular node artery (RAV) had an RGEA-dependent pattern. Fifty percent of grafts (three of six) with a 75% native coronary stenosis at the distal RCA had a balanced pattern. Forty-four percent of grafts (seven of 16) with a 90% native coronary stenosis at the proximal or mid-RCA had an RGEA-dependent flow pattern, whereas 67% of grafts (six of nine) at the distal RCA and 100% of grafts (six of six) at the RPD or RAV had an RGEA-dependent flow pattern. The number of grafts with an RGEA-dependent flow pattern increased significantly as the location of the native coronary stenosis became more distal (Table 4Go).


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  		Table 4. . Flow Patterns According to the Location of Native Coronary Stenosis
 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The ITA has been widely recognized for its excellent patency as an arterial graft in CABG. The RGEA is now being applied clinically as the second most reliable arterial graft. In some studies, the diameter of the RGEA graft was the same size or slightly larger than that of the ITA, as measured by preoperative angiography [8, 9]. However, histologically, the RGEA contains a thick media layer of smooth muscle cells, whereas the ITA has a large number of elastic fibers [10]. This histologic distinction may explain why the RGEA is characterized by stronger spasms than the ITA. In addition, the blood flow of in situ RGEA grafts is influenced by gastric contents [11]. Moreover, Tedoriya and colleagues [12] reported that diastolic and mean pressures in the ITA were significantly higher than in the RGEA graft in 28 patients who underwent CABG. This may be caused by anatomic characteristics, as the RGEA is the fourth branch off of the aorta, whereas the left ITA is the second branch. These three characteristics of the RGEA (stronger spasm, influence of gastric contents, and lower systemic pressure) cause the blood flow of the RGEA to be lower than that of the left ITA, and therefore the RGEA graft competes with the native coronary artery more often than the ITA. Seki and associates [13] initially reported a thinning phenomenon ("string sign") in the ITA graft (ITA to native coronary artery flow ratio <0.50), and the string sign in the ITA has now been observed in many studies. We previously reported that the RGEA has a thinning-down phenomenon (named the "slender sign") in the early postoperative period as a result of flow competition between the RGEA and the native coronary artery [7]. We can easily suppose that the slender sign of the RGEA occurs earlier and more frequently than the string sign of the ITA because of the three characteristics of the RGEA just described.

The blood flow of arterial grafts must be considered from two aspects: a graft side and a native coronary side. The factors on the graft side consist of the graft's pressure, length, and diameter. In our hospital, the RGEA was always dissected at the half of the greater curvature of the stomach, as described in the Surgical Technique section, and then the dissected side was anastomosed to the native coronary artery. The preoperative diameter of the RGEA was not significantly different (2.27 ± 0.33 mm), as we showed in Table 2Go. It is thought that the resistance of the RGEA is almost the same, and therefore the blood flow of the RGEA depends on the condition of the distal coronary artery. We previously reported that the flow of arterial grafts depends on the size of the perfused area, the degree of native coronary stenosis, the viability of the revascularized area, and distal runoff of the native coronary artery when the factors on a graft side were the same [7]. If the site of native coronary stenosis is further proximal and the degree of native coronary stenosis is less severe, then the native coronary artery blood flow may more frequently overcome the RGEA graft blood flow.

According to postoperative angiographic controls, in regard to CABG to an OMI lesion, all 75 grafts anastomosed to an OMI lesion were classified into an RGEA-dependent pattern regardless of the degree of coronary stenosis. Because an OMI lesion requires less blood flow than an angina pectoris lesion, native coronary flow supplies less blood flow to an OMI lesion. However, CABG effectively increases myocardial contraction to an OMI lesion while myocardial viability remains unchanged [14]. Therefore, the blood supply to an OMI lesion increases after CABG [15]. We basically performed CABG to an OMI lesion where myocardial viability remained. This viability was recognized by preoperative iodine-123–ß-methyliodophenyl pentadecanoic acid myocardial images. Therefore, we suppose that graft conduits anastomosed to an OMI lesion have good flow even if the grafts have low blood pressure. An RGEA graft is suitable for CABG to an OMI lesion.

In patients with angina pectoris, the majority of grafts with a 99% stenosis, 61% with a 90% stenosis, and 23% with a 75% stenosis were classified into an RGEA-dependent pattern. Moreover, no grafts with a 75% native coronary artery stenosis located between the proximal and distal RCA, versus 78% of grafts with a 75% native coronary stenosis located at the RPD or RAV, demonstrated an RGEA-dependent flow pattern. On the other hand, 44% of grafts with a 90% native coronary stenosis located at the proximal or mid-RCA, 67% of grafts located at the distal RCA, and 100% of grafts located at the RPD or RAV had an RGEA-dependent flow pattern. The number of grafts with an RGEA-dependent flow pattern increased significantly as the degree of the native coronary stenosis became more severe (99% > 90% > 75%) and as the location of the native coronary stenosis became more distal. Based on these results, an RGEA graft is unsuitable for CABG to an angina pectoris lesion on the RCA with a 75% stenosis located between the proximal and distal RCA. An RGEA graft is possibly unsuitable for CABG to a 90% stenosis located at the proximal or mid-RCA. An RGEA graft is suitable for CABG to a 75% stenosis located at the RPD or RAV and to a 90% stenosis located at the distal RCA or the RPD or RAV and a 99% stenosis of any RCA. Finally, the use of the RGEA as a graft should be based on the preoperative diameter of the RGEA graft determined angiographically and the intraoperative blood flow of the RGEA. For CABG to a lesion with less than 90% stenosis, the right ITA should be used as a graft anastomosed to the proximal or mid-RCA because a right ITA graft generally has more blood flow than the RGEA. On the other hand, a saphenous vein graft should be used for anastomosis to the distal RCA, because a right ITA graft becomes too long to supply enough flow.

In conclusion, flow competition depends on three factors: the viability of the revascularized area, the degree of proximal native coronary artery stenosis, and the location of the stenosis. Right gastroepiploic artery grafts should be selected based on these three considerations.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Uchida, Department of Cardiovascular Surgery, Koseiren Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi-shi, Hiroshima 738, Japan.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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  9. Kawaue Y, Hayashi S. Description of arterial grafts from the aspect of preoperative angiography. J Jpn Assoc Thorac Surg 1994;42:13–7.
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