Ann Thorac Surg 1996;62:1743-1747
© 1996 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Intermediate Clinical Results of Combined Gastroepiploic and Internal Thoracic Artery Bypass
Tadashi Isomura, MD,
Toru Sato, MD,
Kouichi Hisatomi, MD,
Nobuhiko Hayashida, MD,
Hiroshi Maruyama, MD
Second Department of Surgery, Kurume University School of Medicine, Fukuoka, Japan
Accepted for publication June 18, 1996.
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Abstract
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Background. To improve the postoperative results of coronary artery bypass grafting (CABG), the internal thoracic artery (ITA) has become the conduit of choice, with a low operative risk. The gastroepiploic artery as a third arterial conduit for grafting was first reported in 1987, and the early results were reported to be as good as those for the ITA graft. In this report, we present the intermediate-term results of combining ITA and gastroepiploic artery grafts up to 7 years after the operation.
Methods. Between April 1988 and April 1992, 214 patients received CABG with at least one ITA graft and were followed up for more than 3 years. They were divided into two groups: Group I consisted of 155 patients who had CABG using one ITA with or without saphenous vein grafts, and group II consisted of 59 patients who had CABG using an ITA and a gastroepiploic artery with or without saphenous vein grafts. The duration of follow-up for hospital survivors ranged from 36 to 89 months.
Results. There were six late cardiac deaths in group I and one in group II. Fifteen patients complained of recurrent symptoms of angina: 13 in group I and 2 in group II. The actuarial survival rate excluding noncardiac deaths was 95.9% in group I and 96.8% in group II at 7 years (p = not significant). The cardiac event-free rate was 75.4% in group I and 92.2% in group II, which was a significant difference (p < 0.05).
Conclusions. When using both the ITA and gastroepiploic artery, CABG can be performed with minimal operative risk and seems to offer an improved quality of life at least 7 years postoperatively.
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Introduction
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More than 20 years have passed since the internal thoracic artery (ITA) was introduced for coronary artery bypass grafting (CABG) by Green and co-workers [1]. Use of the ITA graft for coronary revascularization has become well established [2, 3] because of the good long-term patency of the graft [4–7]. In contrast, selection of grafts for CABG is becoming complicated because the indications for percutaneous transluminal coronary angioplasty (PTCA) are expanding and more patients require multiple coronary revascularization. For CABG with multiple arterial grafts, the bilateral ITAs ordinarily are used. However, the pedicled gastroepiploic artery (GEA) can be used for right coronary revascularization instead of the pedicled or free right ITA, in addition to the left ITA to the left coronary artery. We have been using the GEA since 1988. This report discusses our intermediate results with combined use of ITA and GEA grafts.
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Material and Methods
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Between April 1988 and April 1992, 214 patients had CABG with at least one ITA graft, and the hospital survivors were followed up for more than 3 years after discharge. Of the total, 155 patients had CABG using a single ITA with or without saphenous vein (SV) grafts (group I), and 59 patients had CABG using the ITA and GEA with or without SV grafts (group II). Their perioperative and late clinical results were evaluated. In group I, the age ranged from 3 years (a girl with Kawasaki disease) to 78 years (mean, 61.6 years), and in group II, the range was 8 years (a boy with Kawasaki disease) to 73 years (mean, 57.1 years). In both groups, most patients had triple-vessel or left main lesions. Left ventricular function was impaired (left ventricular ejection fraction < 0.40) in 9.5% of group I and 11.4% of group II (Table 1
). Although the GEA was not used preferentially for emergent operation, it was used in 11.4% of patients with unstable angina in group II (see Table 1).
Operative Technique
All of the operations were performed by the same surgeon (T.I.). In group II, the midline incision was extended 3 to 6 cm below the xyphoid, and the GEA was taken down through laparotomy as described previously [8]. After general heparin administration, 1 to 2 mL of diluted papaverine (20 mg in 20 mL normal saline) was given intraluminally from the cut end of both the ITA and the GEA to prevent spasm of the grafts. When all three types of conduits (SV, ITA, and GEA) were used, coronary revascularization was performed first with the SV with 7-0 Prolene (Ethicon, Somerville, NJ), then with the GEA with 7-0 or 8-0 Prolene, and finally with the ITA with 7-0 or 8-0 Prolene as a continuous suture. The number of distal anastomoses per patient was 2.7 ± 0.9 (range, 1 to 5) in group I and 3.2 ± 0.6 (range, 2 to 5) in group II. The cardiopulmonary bypass time and mean aortic cross-clamp time were 121 ± 42 minutes and 61 ± 30 minutes in group I, and 138 ± 28 minutes and 70 ± 21 minutes in group II, respectively.
The types of conduits and the grafted coronary arteries for the two groups are shown in Table 2. The arterial conduits were used as pedicled grafts in all procedures. In both groups, the left ITA was generally anastomosed to the left anterior descending coronary artery. In group II, the GEA was anastomosed to the distal right coronary artery (RCA) (posterodescending or atrioventricular branch) in most instances, whereas the left coronary artery was revascularized by the GEA in 8 patients with small RCA. In group II, the right ITA was used in 2 patients, and the inferior epigastric artery was used in 2 patients as additional arterial conduits. The mean number of grafted veins was 1.7 per patient in group I, and the SV was anastomosed to the RCA in 34.7%. In group II, the mean number of grafted veins was 1.1 per patient, and the SV was anastomosed to the RCA in 14.5%.
To determine postoperative morbidity, perioperative myocardial infarction was defined as either electrocardiogram findings of a new onset of Q waves or a maximal level of serum creatine kinase MB fraction greater than 40 U/L. Postoperative respiratory failure was defined as intubation for more than 36 hours after operation. Other operative complications were also compared for the two groups.
Follow-up
Early mortality was defined as postoperative death within the first month. Follow-up information on the patients was collected through direct patient contact, from responses to mailed questionnaires, or from the patient's personal physician. The following postoperative cardiac events were also recorded during follow-up: new myocardial infarction on electrocardiogram, recurrent angina, postoperative intervention such as PTCA or reoperation, and noncardiac death.
Statistical Analysis
Continuous variables are expressed as mean ± standard deviation. The p values refer to the results of Student's t test for continuous variables and 
2 or Fisher's exact test for categoric variables. Patient survival and cardiac event rates were calculated according to the actuarial method. A probability value of less than 0.05 was considered significant.
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Results
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Mortality and Morbidity
Early postoperative mortality was 1.9% in group I: 1 patient died of respiratory failure due to pneumonia, 1 of endotoxin shock, and 1 of graft-versus-host disease after blood transfusion. The mortality in group II was 1.7%: 1 patient died of renal failure after deterioration of preoperative chronic renal failure. Early postoperative morbidity is summarized in Table 3; there was 14.8% in group I and 10.2% in group II. In group II, cautious hemostasis of both the pedicled ITA and GEA was performed before abdominal closure. Then, before closing the chest, we confirmed hemostasis of both the pedicled ITA and the heart, and there was therefore no reoperation for bleeding in group II. There were no significant differences between the groups in postoperative morbidity. Postoperative stroke was not seen in either group, and there were no abdominal complications in group II (see Table 3).
Postoperative angiography was performed in 111 patients (71.8%) in group I and in 44 patients (74.6%) in group II within 3 weeks after operation. In group I, 109 (98.2%) ITA grafts and 183 (95.3%) SV grafts were patent; in group II, 43 (97.7%) ITA grafts, 43 (97.7%) GEA grafts, and 43 (95.7%) SV grafts were patent. The patency rate of arterial or SV grafts was not different between the groups.
Late Cardiac Events
Late deaths occurred in 17 patients; the causes were cardiac in 7 (6 in group I and 1 in group II) and noncardiac in 10 (7 in group I and 3 in group II). In group I, the six cardiac deaths were due to recurring myocardial infarction in 2 patients and congestive heart failure due to unimproved and severely impaired left ventricular function in 4, including 2 patients who received emergency operations after acute myocardial infarction. The one late cardiac death in group II was due to congestive heart failure from prolonged impaired left ventricular function.
Fifteen patients complained of recurring symptoms of angina: 13 patients in group I and 2 in group II. They were first treated medically; however, 11 patients in group I and 1 in group II required readmission and underwent a repeat angiogram. In group I, the results showed occlusion of the SV graft in 4, stenosis of the SV graft (vein graft disease) in 3, and new occurrence of substantial stenosis in the native coronary artery in 3 patients. The lesion in the SV was in the graft to the RCA in 4 and the graft to the obtuse marginal branch in 3. One patient showed string sign of the ITA to the left anterior descending artery, and this patient had repeat CABG. One patient in group II showed a new lesion in the native coronary artery. The stenotic lesions of the SV graft or native coronary artery were dilated successfully by PTCA in both groups, relieving the patients' symptoms. Late myocardial infarction occurred in 3 patients, 2 in group I and 1 in group II.
In group II, 3 patients received abdominal operations in the late period; 2 were operated on for abdominal aortic aneurysm and 1 for colon cancer. The abdominal operations were performed uneventfully in all patients. The New York Heart Association classification after operation in group I was class I for 77, class II for 56, class III for 4, and class IV for 1, who suffered a stroke in the late period. In group II, the categories were class I for 40, class II for 13, and class III for 2, who had repeated heart failure due to impaired left ventricular function or respiratory dysfunction due to chronic bronchitis. The duration of follow-up for hospital survivors ranged from 36 to 89 months (average, 51.6 months in group I and 54.1 months in group II). The cumulative follow-up for group I was 653.1 patient-years and for group II was 261.4 patient-years.
Actuarial survival excluding noncardiac deaths (Fig 1A) was 95.9% in group I and 96.8% in group II at 7 years, and the cardiac event-free rate (Fig 1B) was 75.4% in group I and 92.2% in group II. The mortality per patient-year was 0.92% for group I and 0.38% for group II. The rate of cardiac events per patient-year was 3.1% for group I and 0.77% for group II, a significant difference (p < 0.05). Repeated angiogram of the GEA was performed in 7 patients. The GEA had been anastomosed to the RCA in 5 and to the LAD in 2 (Fig 2), and the graft was patent in all patients.
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Fig 1. . (A) Survival rates excluding noncardiac deaths after operation in group I (patients receiving coronary artery bypass grafting using one internal thoracic artery with or without saphenous vein graft) and in group II (patients receiving coronary artery bypass grafting using both the internal thoracic and gastroepiploic arteries with or without saphenous vein graft). There is no significant difference (NS) in the survival rates between group I and group II up to 7 years after operation. (B) Cardiac event-free rates after operation in group I and in group II. There is a significant difference between the groups at 6 years after operation (p < 0.05).
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Fig 2. . Angiogram taken 69 months after operation. The right gastroepiploic artery is patent, and the left anterior descending branch is clearly demonstrated by the flow through the gastroepiploic artery, with no sclerotic changes.
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Comment
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More than 20 years have passed since the ITA was first used as a graft conduit for CABG [1], and the superior patency of ITA grafts and the improvement of symptoms after CABG with the ITA have been well established [2, 3]. Coronary angioplasty has become common, and most patients require multiple coronary artery revascularization. In theory, the use of bilateral or sequential ITA grafts can extend the degree of myocardial revascularization with arterial grafts. Cameron and associates [9] reported the excellent results of freedom from symptoms 15 years after CABG in patients with single or multiple ITA grafting, whereas Morris and colleagues [10] suggested that routine multiple ITA grafting resulted in negligible survival benefit.
In 1987, the GEA was reported as a new arterial conduit for CABG [11–13], with good patency and clinical results, at least in the early postoperative period [8, 14–16]. Although a laparotomy is necessary to harvest the GEA graft, the GEA can be used as a pedicled graft in most instances and can reach to the distal RCA, the left anterior descending branch, or even to the distal obtuse marginal branches (to which it is difficult to apply the pedicled right ITA) through the diaphragm by passing the stomach anteriorly. As mentioned in our previous report, the pedicle of the GEA contains more adipose tissue than that of the ITA, and the distal diameter is larger even in a patient with a small structure, such as the 8-year-old boy with Kawasaki disease [8, 17]. In 1988 we started to use the GEA in young patients, as previously reported [8], because we expected the same long-term benefits as with the ITA graft. We have used the GEA as a pedicled graft in more than 100 patients. When comparing the GEA with the use of bilateral ITAs, we prefer to use the left ITA and GEA grafts because they can be used as pedicled arterial grafts to any coronary artery, and postoperative sternal infection seems to occur very rarely. The early patency rate and improvement of symptoms and exercise performance after grafting were excellent, as we reported earlier [18]. In this report, we reviewed the intermediate results in patients who received multiple arterial grafting with the ITA and the GEA and who were followed up for more than 3 years. In combined use of the ITA and GEA grafts, the left coronary artery is revascularized by the left ITA, and the RCA by the GEA in most patients. In contrast, the RCA is usually revascularized by the SV graft in patients with a single ITA graft combined with a vein graft. The patients receiving combined use of the ITA and GEA were younger and had more severe coronary lesions than those with a single ITA. However, actuarial survival in the patients with both ITA and GEA grafts proved satisfactory and comparable to that reported for bilateral ITA grafts [19–21]. Early results with the GEA graft are consistently reported to be as good as those of the ITA graft.
Recently, Suma and co-workers [22] reported their clinical and angiographic midterm results in 200 patients with a GEA graft. The rate of graft patency at a mean of 2 years after the operation was 95% in 40 patients with a repeated angiogram, which was equivalent to that in the early postoperative period. Jegaden and associates [23] also reported the results of CABG with bilateral ITA and GEA grafts at a mean of 20 months, and concluded that the technique can be achieved with minimal operative risk and offers good functional results and midterm survival rate. In our study of patients followed up more than 3 years after CABG, the late cardiac event rate was as low as 0.77% per patient-year in patients with both ITA and GEA grafts, with better relief of symptoms than in patients with a single ITA graft. In the late follow-up, PTCA was performed in 11 of 12 patients who required readmission because of recurrent angina: 7 with vein graft deterioration (all in group I) and 4 with new coronary lesions (3 in group I and 1 in group II).
Four patients in group I and none in group II had postoperative cardiac events, as judged by ischemic change in the inferoposterior wall that had been revascularized by the SV graft. Therefore, the GEA seemed to be more durable than the SV graft. Although the longest interval of follow-up was 7 years 5 months and the average was 54.1 months, none of the patients have required reoperation for CABG, and only 1 patient needed PTCA after CABG using both ITA and GEA grafts. Freedom from angina in the late period was 92.2% at 7 years.
Although our study included few patients who had repeated angiograms, the patency of the GEA in the repeated angiograms was good, as described also in the report of Suma and co-workers [22]. We also found previously a growth potential for the GEA graft in a child [24]. Our current study describes the low operative risk for patients receiving CABG with both ITA and GEA grafts as pedicled conduits; moreover, this procedure offers improvement of cardiac symptoms and is expected to provide long-term benefit. Although it is time-consuming to harvest the GEA in the thick adipose tissue of obese patients or in emergent situations, the combined use of the ITA and the GEA may become a routine technique to revascularize multiple coronary arteries, providing low operative risk, few leg incisions, and excellent late results.
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Acknowledgments
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This work was supported in part by a research grant from the Ministry of Health and Welfare (C-07671492).
We thank Drs Hisayoshi Suma and Taikoh Horii for their valuable discussion and review of the manuscript.
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Footnotes
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Address reprint requests to Dr Isomura, Department of Surgery II, Kurume University Hospital, 67 Asahi-Machi, Kurume, Fukuoka 830, Japan.
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References
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Abstract
Introduction
