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Ann Thorac Surg 2001;71:1205-1209
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Sequential grafting of the right gastroepiploic artery in coronary artery bypass surgery

Masami Ochi, MDa, Ryuzo Bessho, MDa, Yoshiaki Saji, MDa, Masahiro Fujii, MDa, Nobuo Hatori, MDa, Shigeo Tanaka, MDa

a Department of Surgery II, Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan

Accepted for publication November 18, 2000.

Address reprint requests to Dr Ochi, Department of Surgery II, Cardiovascular Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
e-mail: ochi/surg2{at}nms.ac.jp


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. Only a few studies have been done on sequential grafting using the right gastroepiploic artery (GEA).

Methods. Forty patients (35 males, ages 36 to 74 years) who underwent sequential grafting of the GEA were reviewed. Angiography of the GEA was performed preoperatively in all patients. GEAs with a luminal diameter greater than 2 mm at the presumptive distal anastomosis on the angiogram were used. The dissected GEA was led into the pericardial cavity through the antegastric route. We used GEAs to graft 89 branches (2.2 per patient) in the inferoposterior region.

Results. In 24 patients who had angiographic examinations, all the GEAs were patent, although luminal narrowing was noted in the segment between the two anastomoses in 3 patients. Eight-year actuarial survival was 92.5% and the cardiac-related event-free rate was 95%.

Conclusions. Sequential grafting of the GEA can be performed effectively in selected patients. Performing preoperative angiography to assess the size of the GEA for sequential grafting is strongly recommended.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
The superior patency rate of the left internal thoracic artery (LITA) in coronary artery bypass grafting (CABG) is well known. The use of internal thoracic artery (ITA) has improved the long-term survival of patients [1, 2]. In addition, the right gastroepiploic artery (GEA) is now widely used as a graft for the coronary artery [3, 4] and the indication, as well as the operative technique, has been established [5–7].

We attempted to perform sequential grafting of in situ arterial grafts to ensure revascularization of several coronary arteries by the grafts [8]. Although it is a technically demanding procedure, sequential grafting of in situ arterial grafts can provide better results. Although several reports on sequential grafting of the ITA have appeared in the literature [8–10], little data are available so far regarding the indications and results of sequential grafting of the GEA [8]. The aim of this study was to clarify the feasibility and efficacy of sequential grafting of the GEA, as well as the indications for it.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Of 690 patients who underwent CABG from June 1991 to December 1999, 280 patients underwent CABG using the GEA at our institute. Sequential grafting of the GEA was performed in 40 of the 280 patients (14.3%). They included 35 males and 5 females with ages ranging from 36 to 74 years, with a mean of 60.4 years. Six patients had double-vessel disease, 34 had triple-vessel disease, and 1 patient had a lesion of the left main trunk. Twenty-nine patients were diabetic, but only 3 of them were insulin-dependent. Seven patients were in unstable conditions; complications included acute myocardial infarction in 3 patients and old myocardial infarction in 19 patients. Thirty-seven patients were operated on electively and 3 patients had emergency operations. No patient had a previous history of CABG, while 4 patients had undergone at least one percutaneous transluminal coronary angioplasty. No patient was under intraaortic balloon pumping (IABP) support preoperatively (Table 1).


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  		Table 1. Patient Characteristics

 
To evaluate if the size of the GEA was adequate for sequential grafting, we performed preoperative selective or semiselective angiography of the GEA in all patients. After completion of the diagnostic catheterization, once the patient was considered to be a candidate for CABG, an angiographic catheter was placed in the celiac artery and was advanced to the origin of the GEA. The stomach was dilated with a gas-producing tablet, and a GEA-angiogram was obtained on the same cinefilm as the coronary angiogram. GEAs of adequate length with a luminal diameter no smaller than 2 mm at presumptive anastomotic points on the angiogram were used as sequential grafts.

Initially, we dissected the GEA as a pedicled graft with surrounding fatty tissue and veins still attached and skeletonized it only around the anastomosis for about 5 to 6 cm. More recently, however, we have been dissecting the GEA in a semi-skeletonized or fully-skeletonized manner using ultrasound cautery (Harmonic Scalpel, Ethicon Inc, Somerville, NJ) to obtain the maximal length of the graft and to facilitate a side-to-side anastomosis. The artery was led into the pericardial cavity anteriorly to the pylorus through a small opening in the diaphragm just above the left lobe of the liver. No standard free blood flow rate of the artery for the sequential graft was instituted. Vasodilating agents were not administered routinely in the artery unless a spasm was suspected.

During sequential grafting, a proximal side-to-side anastomosis was first constructed. The proximal anastomosis was performed primarily in a parallel manner so that the graft was attached to the coronary artery longitudinally to obtain an anastomosis of suitable size. When the caliber of the GEA was large enough (usually more than 3 mm), a diamond anastomosis was constructed if indicated. In a parallel anastomosis, the length of the arteriotomy of the graft for the side-to-side anastomosis was made slightly longer than that of the coronary artery to avoid deformity of the graft by stretching at the anastomosis site. Anastomosis was carried out with a single 7-0 or 8-0 monofilament continuous suture with the aid of magnification (4 x).

Overall, 3 to 6 distal anastomoses (total 173, 4.3 on average) were constructed per patient. The ITAs revascularized 67 branches (38.7%) and were anastomosed to the LAD in 39 patients. Sequential grafting of the left internal thoracic artery (LITA) was performed in 16 patients. The right internal thoracic artery (RITA) was used as a composite graft with the LITA in 4 patients. The GEAs revascularized 89 branches (51.4%; 2 to 3 per patient, mean 2.2) of the inferior to posterior region. In addition, the saphenous vein was used in 10 patients to graft 17 branches (9.8%); most of these were proximal segments of the right coronary artery or the circumflex artery (Table 2).


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  		Table 2. Grafts and Distal Anastomoses

 
Statistical analysis
Nonparametric, nonrisk-adjusted estimates of actuarial survival and cardiac-related event-free rates were obtained by Kaplan-Meier’s method [11]. In calculating the cardiac-related event-free rates, the following events were included: acute myocardial infarction, recurrence of angina, requirement of percutaneous transluminal coronary angioplasty and re-CABGs.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
There were two hospital deaths; 1 patient died of sepsis and 1 died of cerebral infarction. The causes of these deaths were not related to the GEA sequential anastomotic technique. One patient suffered from renal failure, which improved by the time of discharge.

Angiographic examination was performed in 24 patients, 3 to 84 postoperative months (mean 5.4 months). The GEA was patent in all patients (Figs 1, 2). The 24 LITAs (11 sequential), 6 RITAs (4 composite T-graft), and 5 saphenous veins were also patent; although one anastomosis of a sequential venous graft was occluded. A diffuse luminal narrowing on the angiogram due to flow competition between the grafted coronary artery was noted in the distal segment of the GEA between the two anastomoses in 3 patients. This phenomenon was also noted in one LITA grafted to the LAD of less than 75% stenosis.



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  		Fig 1. Angiogram of triple sequential grafting of the gastroepiploic artery (GEA) taken 1 year postoperatively. The GEA was anastomosed to the posterior descending and atrioventricular branches of the right coronary artery and the ramus intermedius branch (arrow) of the left coronary artery (LCA).

 


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  		Fig 2. An angiogram taken 7 years postoperatively. The gastroepiploic artery was anastomosed to the atrioventricular branch of the right coronary artery (black arrow) and to the posterolateral branch of the circumflex artery (white arrow).

 
There was one late death at 20 months’ follow-up but the cause of death was noncardiac. No cardiac-related event occurred in the operative survivors. The actuarial survival rate and cardiac-related event-free rate of the patients were 92.5% (95% confidence interval: 83.3% to 100%) and 95% (95% confidence interval: 88.2% to 100%), respectively at follow-up periods of 9 years and 8 months (Figs 3, 4).



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  		Fig 3. Actuarial survival rate according to the Kaplan-Meier estimation; 95% confidence limits = 83.3% to 100%.

 


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  		Fig 4. Freedom from cardiac events, including angina, acute myocardial infarction, PTCA and redo CABG; 95% confidence limits = 88.2% to 100%.

 


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  		Fig 5. The gastroepiploic artery (GEA) was anastomosed to the posterior descending branch of the right coronary artery and the posterolateral branch of the circumflex artery. The luminal diameter of the GEA was 3.5 mm at the proximal anastomosis (white arrow) and 2.8 mm at the distal anastomosis (black arrow).

 


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  		Fig 6. An angiogram taken 2 years postoperatively. The gastroepiploic artery (GEA) was anastomosed to the posterior descending and atrioventricular branches of the right coronary artery. The luminal diameter of the GEA was 3.3 mm at the proximal anastomosis (black arrow) and 2.9 mm at the distal anastomosis (white arrow).

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
To utilize in situ arterial grafts for as many coronary branches as possible, we have aggressively performed sequential grafting of both the ITA and the GEA [8]. With the sequential grafting technique, the entire coronary system can be grafted using only in situ arterial grafts with an excellent patency rate even in patients requiring multiple revascularization. We have grafted a maximum of six branches using only in situ LITA and GEA in this series [12].

For revascularization of the right coronary system, the RITA is often the graft of choice. However, in most instances, the in situ RITA cannot reach the distal branches of the right coronary artery. The RITA can be used as a free graft to make a composite T- or Y-graft with the LITA [13]. We prefer this form of composite graft. However, because of the available length of the RITA in our patients, the regions that could be grafted by the T-graft were limited to within the left coronary system.

The radial artery has been widely used since its revival for CABG [14]. The number of CABGs using the radial artery has been increasing at our institute. The radial artery is another graft of choice for the branches of the inferoposterior region. However, inasmuch as its characteristics are fully understood, a GEA of satisfactory length and caliber is still the graft of choice for the inferoposterior region.

There are several factors influencing the performance of sequential grafting of the GEA.

First, when using the GEA, a longer graft is needed to reach the heart than with the ITA [15, 16]. In sequential grafting, when a longer graft is necessary, the luminal diameter of the GEA at the distal anastomosis is usually much narrower than at the proximal segment. When the GEA is relatively small and the lesion of the coronary artery is not critical, flow competition between the GEA and the coronary artery can easily occur [5, 7, 17].

Second, the GEA is a third branch of the abdominal aorta, while the ITA is a second branch of the aortic arch. Consequently, the diastolic pressure is significantly lower in the GEA than in the ITA, leading to a considerable difference in the diastolic flow characteristics [18]. Thus, the GEA may be less capable of perfusing the coronary artery than the ITA. To generate adequate perfusion pressure, the GEA should have a large luminal diameter (2 to 3 mm) at its anastomotic point [19].

Third, unlike the ITA, the luminal diameter and length are not consistent in the GEA. The LITA can be used as a sequential graft without confirming its size before the operation. In contrast, sequential grafting of the GEA is not always possible since the GEA shows a wider variation in its length and caliber than the ITA [5, 6].

Therefore, sequential grafting of the GEA should be performed only when the adequacy of its length and luminal diameter has been confirmed. This is the main reason why the number of patients in this series is relatively small.

It is helpful to know the size of the GEA before entering the peritoneal cavity. We evaluated if the GEA was of suitable size for sequential grafting from the findings of the preoperative angiograms. The angiogram of the GEA was obtained during diagnostic cardiac catheterization by cardiologists once the patient was considered a candidate for CABG.

Our indication for sequential grafting was that the luminal diameter of the GEA on the angiogram should be no smaller than 2 mm at the presumptive distal anastomotic point [5, 8]. This means that the luminal diameter of the artery at the proximal anastomosis would be as large as 3 mm or more.

We measured the luminal diameter of the GEA from the postoperative angiograms in 10 patients (unpublished data). These measurements were carried out by means of the computer-analyzed Quantitative Coronary Angiography method. The estimated luminal diameter of the GEA around the proximal and distal anastomosis was 3.1 ± 0.9 mm and 2.7 ± 0.8 mm, respectively. (The values are expressed as mean ± standard deviation) (Figs 5,6).

We also evaluated the flow capacity of the GEA in these patients by performing dobutamine stress echocardiography, which is a sensitive diagnostic means for detecting regional myocardial hypoperfusion [20]. Eight patients whose GEAs were no smaller than 2.5 mm at the distal anastomosis exhibited no ischemic wall motion abnormality in the region where the GEA had been grafted. Two patients who showed ischemic wall motion abnormality in the region grafted by the GEA had GEAs of small luminal diameter (2.0 mm and 1.8 mm at the proximal anastomosis). The distal segment of the GEA between the two anastomoses was diffusely narrowed. These two patients were included in the initial period of this series and might have been unsuitable cases for sequential grafting. Although the number is small, this observation may support the idea that a large luminal diameter at the distal anastomosis is a necessary and sufficient condition for sequential grafting of the GEA.

Harvesting the GEA by semi- or full skeletonization is our current principle. The GEA is frequently surrounded by profuse fatty tissue. Although it takes longer to dissect the entire length of the GEA, skeletonization can make sequential anastomosis much easier [21]. In addition, it can make a greater length of the GEA available so that anastomoses can be constructed at a more proximal point of the GEA where the luminal diameter is wider.

Regarding the route of the GEA to the heart, the retrogastric route covers a shorter distance and may be more appropriate for the distal branches of the right coronary and circumflex arteries than the antegastric route [22]. Some surgeons prefer the retrogastric route as they can construct the anastomosis more proximally to obtain a more efficient free blood flow [19]. Although we have not yet used the retrogastric route, we believe it may be advantageous for sequential grafting of the GEA.

In conclusion, sequential grafting of the GEA may be as useful as that of the ITA for multiple coronary revascularization using in situ arterial grafts. The midterm results were satisfactory. Since the luminal diameter of the GEA is a major factor that influences the outcome of the graft, preoperative angiography of the GEA may be mandatory to assess the adequacy of the size of the artery for sequential grafting.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Lytle B.W., Loop F.D., Cosgrove D.M., Ratliff N.B., Easley K., Taylor P.C. Long-term (5 to 12 years) serial studies of internal mammary artery, and saphenous vein coronary bypass grafts. J Thorac Cardiovasc Surg 1985;89:248-258.[Abstract]
  2. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Influence of the internal mammary artery graft on 10-year survival and other cardiac events. New Engl J Med 1986;314:1-6.[Abstract]
  3. Suma H., Fukumoto H., Takeuchi A. Coronary artery bypass grafting by utilizing in situ right gastroepiploic artery: basic study and clinical application. Ann Thorac Surg 1987;44:394-397.[Abstract]
  4. Pym J., Brown P.M., Charrette E.J.P., Parker J.O., West R.O. Gastroepiploic-coronary anastomosis. A viable alternative bypass graft. J Thorac Cardiovasc Surg 1987;94:256-259.[Abstract]
  5. Mills N.L., Hockmuth D.R., Everson C.T., Robart C.C. Right gastroepiploic artery used for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1993;106:579-586.[Abstract]
  6. Grandjean J.G., Boonstra P.W., den Heyer P., Ebels T.E. Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients. J Thorac Cardiovasc Surg 1994;107:1309-1316.[Abstract/Free Full Text]
  7. Albertini A., Lochegnies A., El Khoury G., et al. Use of the right gastroepiploic artery as a coronary artery bypass graft in 307 patients. Cardiovasc Surg 1998;6:419-423.[Medline]
  8. Ochi M., Yamada K., Ishii Y., et al. Impact of sequential grafting of the internal thoracic or right gastroepiploic arteries on multiple coronary revascularization. Cardiovasc Surg 2000;8:386-392.[Medline]
  9. Kabbani S.S., Hanna E.S., Bashour T.T., Crew J.R., Ellertson D.G. Sequential internal mammary-coronary artery bypass. J Thorac Cardiovasc Surg 1983;86:697-702.[Abstract]
  10. Van Sterkenburg S.M.M., Ernst S.M.P.G., de la Riviere A.B., et al. Triple sequential grafts using the internal mammary artery: an angiographic and short-term follow-up study. J Thorac Cardiovasc Surg 1992;104:60-65.[Abstract]
  11. Kaplan E.L., Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457-481.
  12. Ochi M., Yamauchi S., Yajima T., Bessho R., Yamada K., Tanaka S. "Hexatuple" coronary bypass with in situ arterial grafts. Jpn J Thorac Cardiovasc Surg 1998;46:402-405.[Medline]
  13. Tector A.J., Amundsen S., Schmahl T.M., Kress D.C., Peter M. Total revascularization with T grafts. Ann Thorac Surg 1994;57:33-39.[Abstract]
  14. Acar C., Jebara V.A., Portoghese M., et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-660.[Abstract]
  15. Saito T., Suma H., Terada Y., Wanibuchi Y., Fukuda S., Furuta S. Availability of the in situ right gastroepiploic artery for coronary artery bypass. Ann Thorac Surg 1992;53:266-268.[Abstract]
  16. Nishida H., Endo M., Koyanagi H., Koyanagi T., Nakamura K. Coronary artery bypass grafting with the right gastroepiploic artery and evaluation of flow with transcutaneous Doppler echocardiography. J Thorac Cardiovas Surg 1994;108:532-539.[Abstract/Free Full Text]
  17. Uchida N., Kawaue Y. Flow competition of the right gastroepiploic artery graft in coronary revascularization. Ann Thorac Surg 1996;62:1342-1346.[Abstract/Free Full Text]
  18. Tedoriya T., Kawasuji M., Sakakibara N., Ueyama K., Watanabe Y. Pressure characteristics in arterial grafts for coronary bypass surgery. Cardiovasc Surg 1995;3:381-385.[Medline]
  19. Dietl C.A. Vascular reactivity of the gastroepiploic artery graft. J Thorac Cardiovasc Surg 1995;110:1568-1569.[Free Full Text]
  20. Kishida H., Kusama Y., Homma H. Dobutamine stress echocardiography for the detection of coronary artery disease and viable myocardium. Jpn Heart J 1997;38:151-161.[Medline]
  21. Gagliardotto P., Coste P., Lazreg M., Dor V. Skeletonized right gastroepiploic artery used for coronary artery bypass grafting. Ann Thorac Surg 1998;66:240-242.[Abstract/Free Full Text]
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