Ann Thorac Surg 2005;79:1606-1609
© 2005 The Society of Thoracic Surgeons
Original articles: Cardiovascular
Gastroepiploic Artery Minimally Invasive Grafting in Reoperative Patients With Patent Mammaries
David Glineur, MDa,*,
Philippe Noirhomme, MDa,
Alain Poncelet, MDa,
Claude Hanet, MDa,
Parla Astarci, MDa,
Robert Verhelst, MDa,
Pierre Yves Etienne, MDa,
Gebrine El Khoury, MDa
a Department of Cardiovascular Pathology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
Accepted for publication October 20, 2004.
* Address reprint requests to Dr Glineur, Service de Chirurgie Cardiovasculaire et Thoracique, Cliniques Universitaires Saint-Luc, U.C.L., Avenue Hippocrate 10, B, 1200 Bruxelles, Belgium
(E-mail: dglineur{at}hotmail.com).
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Abstract
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BACKGROUND: Patients with patent grafted bilateral internal thoracic arteries may require repeat myocardial revascularization because of either progression of disease in a nongrafted native vessel or failure of a saphenous vein graft. In order to avoid extensive dissection and possible damage of the internal thoracic arteries, we elected to proceed with an off-pump minimally invasive direct coronary artery bypass grafting (MIDCABG) approach using the pedicled right gastroepiploic artery. This paper summarizes our midterm angiographic results.
METHODS: From 1996 to 2003, 15 patients were reoperated on using this approach in our department. Internal thoracic artery grafts always revascularized the anterior and lateral territories and were angiographically patent. Indications for repeated surgery were: (1) coronary disease progression in 8 patients; (2) occlusion of the saphenous vein graft in 6 patients; and (3) anastomotic stenosis of a pedicled right gastroepiploic artery in 1 patient. Off-pump grafting of the pedicled right gastroepiploic artery was targeted at the posterior descending artery in 14 patients, and at the left anterior descending artery in 1 patient.
RESULTS: Thirty-day mortality was 6.5% (1 of 15 patients). With a mean follow-up of 56 ± 20 months, angina-free survival was 79%. At angiographic control (mean, 38 months), the pedicled right gastroepiploic artery was patent in 13 patients. One patient had an occluded right gastroepiploic artery graft at 23 months and another patient showed progression of disease distal to the right gastroepiploic artery anastomosis at 28 months.
CONCLUSIONS: Off-pump MIDCABG repeat revascularization with a pedicled right gastroepiploic artery is an effective method of revascularization for patients with patent bilateral internal thoracic arteries.
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Introduction
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Reoperation in patients with patent bilateral internal thoracic arteries (ITAs) is always a surgical challenge because of hazards of sternal reentry, potential damage to the conduits during dissection of the heart, and problems with myocardial protection [1, 2]. Reoperation in patients with one patent ITA has been well-studied and, in experienced hands, does not seem to increase early mortality or morbidity using retrograde cardioplegia for myocardial protection [3–5]. Results of reoperation in patients with two patent ITAs have not been widely reported. The recent development of minimally invasive direct coronary artery bypass (MIDCAB; CardioThoracic Systems, Inc, Cupertino, CA), and its utilization in the reoperation (redo) setting has the theoretical advantages of the following: (a) avoidance of graft or aortic manipulation; (b) avoidance of sternal reopening; and (c) no requirement for cardiopulmonary bypass. Left anterior minithoracotomy, ministernotomy, and posterolateral thoracotomy are some of the innovative techniques that have been proposed to graft the anterior territory [6–10]. For the right coronary system, Grandjean and colleagues [11] were the first to report grafting of the right gastroepiploic artery (RGEA) to the posterior descending artery on the beating heart by MIDCABG. After this initial technical description, Fonger and colleagues [12] published the largest series using this approach in redo patients and conclude that there was a lower graft patency rate than expected and there was a significant mortality associated with these high-risk patients.
A number of patients with bilateral internal thoracic arteries (BITA), directed toward the left coronary system, may present with recurrence of ischemia related to either a progression of native disease or to the occlusion of a preexisting graft on the right coronary system. Over the last seven years, we have performed 15 of these MIDCABG procedures using a pedicled RGEA to revascularize the right coronary system in patients with patent BITAs. Over the last decade, our policy of revascularization for the right coronary system was to use the gastroepiploic artery only in very young patients (<50 years), with a stenosis greater than 70%. For all other patients, we used a saphenous vein graft. This article summarizes our experience with this technique and analyzes the clinical results of this type of surgery as well as the midterm patency rate of the grafted RGEA.
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Patients and Methods
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Patients
Between August 1996 and June 2003, 3,914 coronary artery bypass grafting (CABG) procedures were performed in our institution. Out of these, 1,370 patients received BITAs, and 234 (6%) procedures were repeated revascularization for angina recurrence. Of these, 90 patients (35%) were reoperated using a pedicled RGEA for bypassing the right coronary system.
Within this subgroup, 15 patients were reoperated by MIDCABG without cardiopulmonary bypass (0.004% of 3,914 patients) and represent the patient cohort for this retrospective study. All these patients suffered from moderate to severe angina refractory to maximal medical treatment. Reoperation was decided upon agreement with the referring cardiologist, after exclusion of the possibility of a nonsurgical percutaneous approach. The mean age of these patients was 60 ± 18 years. Thirteen patients were males.
All patients had patent BITAs. The mean number of anastomoses per patient was 3.2 and the mean number of arterial anastomoses per patient was 2.6. One patient had an RGEA grafted on the posterior descending artery (PDA). All patients but one were in Canadian Classification Score (CCS) grade 3 angina, the latest being in class 4. All procedures were elective. Mean left ejection fraction was 58% ± 13%. Mean time interval from the first operation to the reintervention was 101 ± 52 months. Mean number of angiography per patients before reoperation was 2.65 (range, 1 to 7). Nine patients (60%) underwent a total of 18 percutaneous transluminal coronary angioplasties (PTCA). Ten PTCAs were performed on the right coronary artery and 6 PTCAs on a stenotic saphenous vein graft. One patient required two successive PTCAs of the RGEA-to-PDA anastomosis. The details of the first procedures, and of the preoperative angiography, are shown in Table 1.
Indication for surgery was progression of the disease in 8 patients (53%), occlusion of a previously grafted saphenous graft in 6 (40%), and anastomotic stenosis of a gastroepiploic artery in one (7%). At repeat surgery, all RGEA were grafted to the PDA except one that was grafted to the distal left anterior descending (LAD) artery. The patient, grafted on the LAD, had a patent left internal mammary artery (LIMA)-LAD anastomosis but had a more distally located stenosis that appeared 141 months after the first operation. The LAD was grafted with the RGEA in a retrograde fashion at the apex of the heart.
Surgical Technique
A 15-cm incision at the inferior part of the previous sternotomy was made, and the xiphoid process resected. The harvesting technique of the RGEA was described previously by our group [13]. All gastroepiploic arteries had at least a diameter of 1.5 mm on visual inspection.
After the dissection of the posterior part of the sternum from the mediastinum, the inferior aspect of the heart was dissected free from the diaphragm. In five patients xiphoid process resection was sufficient to reach the PDA. In the other 10 patients, a T-shaped incision of the lower third of the sternum was made in order to gain adequate exposure to the target vessel.
The inferior aspect of the heart was elevated using two traction sutures (silk, 2–0; Johnson & Johnson, European Logistics Center, Belgium) inserted in the diaphragm at the level of the PDA. The PDA was then dissected and a 4–0 Gore-Tex (Gore-Tex CV-7: WL Gore & Associates, Flagstaff, AZ) suture passed around the vessel distal and proximal to the arteriotomy site to allow vessel occlusion if intracoronary shunting was not feasible. The heart was only stabilized by 2 to 4 stitches of Prolene 6–0 (Ethicon, Somerville, NJ) passed in the epicardium near the anastomotic site because minimal dissection did not give enough space to use a classic stabilizer. As such, this allowed us to obtain an adequate stabilization of the future anastomotic site. The pedicled RGEA was routed through a cruciform incision in the diaphragm, anterior to the inferior vena cava, to obtain a perfect lie in front of the target vessel (PDA).
The anastomosis was performed with a continuous 8–0 polypropylene suture on the beating heart. An intracoronary shunt was used in 40% (6 of 15) of the patients, whereas for the other patients a temporary proximal occlusion was necessary to obtain a blood-free surgical field.
Design of the Study
The design of the study was approved by the hospital ethical committee. This study is retrospective in nature but it includes all consecutive patients who underwent repeat revascularization on the right coronary system with patent BITA during the study period.
During follow-up all patients were examined by their referring cardiologists one month postoperatively. Thereafter a stress test was performed annually. A control coronary angiography was obtained postoperatively even in asymptomatic patients.
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Results
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The mean operative time was 90 ± 35 minutes. There were no conversions to full sternotomy or operative deaths. The median intensive care unit stay was 1 day. No patient required blood transfusion. One patient developed an acute inferior myocardial infarction on the seventh postoperative day with severe right ventricle dysfunction. At angiography the gastroepiploic artery was occluded. This patient was reoperated on by full sternotomy and cardiopulmonary bypass. A saphenous vein graft was anastomosed on the right coronary system. However, the patient died on postoperative day 10 from multiorgan failure. One patient had to be reexplored for bleeding on day of the operation. No other adverse events were encountered in the other patients.
Mean postoperative hospital stay was 5 days (range, 3 to 9 days). Mean clinical follow-up was 56 ± 20 months. At follow-up 11 patients were asymptomatic, whereas 3 patients had angina recurrence (21%); two were in CCS class II and one in class III. Of these 3 patients, one had stenosis of a saphenous vein graft to a marginal branch and was treated by PTCA stenting 21 months after the second operation. The second patient developed recurrent angina with a patent RGEA because of a new stenosis on the distal PDA one centimeter distal to the anastomotic site, 28 months after the reoperation, and was treated medically. The last symptomatic patient was found to have an occluded RGEA artery 23 months after MIDCABG. He was also treated medically after two failed attempts of desocclusion. The RGEA was found to be patent in the other 13 patients with a mean angiographic follow-up time of 38.3 ± 14 months. One of these patients, although asymptomatic, had a stenosis on the celiac trunk. Late follow-up results are depicted in Table 2.
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Comment
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Even though the use of the left ITA, and more recently the right ITA, has been shown to dramatically improve long-term angina free recurrence and overall survival in patients undergoing myocardial revascularization, the continuous increase of a patient's life expectancy implies that reoperative coronary procedures are becoming more frequent in most cardiac centers, ranging from 6% to 15% [14]. Over the last decade, although mortality and morbidity associated with repeat surgical procedures have decreased, they still remain a significant issue [3, 5]. Currently, patients presenting for repeat revascularization may have had a variety of "arterial" revascularization procedures during their primary operation and represent a complex and challenging cohort of patients whenever reoperation is required. The presence of a patent ITA has recently not been found to be a significant variable associated with in-hospital mortality if the operation was performed by an experienced surgeon using retrograde cardioplegia [2–4].
Technical problems of reoperations in the setting of additional patent arterial grafts are well-appreciated and several authors have studied the respective roles of MIDCABG and OPCABG in this setting [6–8]. Indeed, Stamou and colleagues [15] found a significant difference concerning in-hospital mortality in favor of the off-pump group (10% vs 1%) in patients undergoing repeated revascularization. Early results using these techniques appear to be acceptable but controversy still exists regarding the long-term outcome of the grafts when these techniques are applied to the general "population" of patients undergoing revascularization [16]. However, in the setting of repeated revascularization, especially in patients with patent arterial grafts, these less invasive techniques may present several advantages when compared to "conventional" reoperation. This assumption is particularly true in high-risk patients with patent bilateral internal thoracic arteries and single-vessel disease on the right coronary system [11, 12]. These include the avoidance of reentry dissection as well as the recognized advantage of a "no touch" technique. Gillinov and colleagues [17], in a series of 35 patients with damage of the patent LIMA in repeated revascularization, demonstrated a 40% incidence of acute myocardial infarction in these patients illustrating the adverse effect of this technical complication.
Most series describing reoperative surgery refer to patients initially operated upon with the exclusive use of the saphenous vein graft (SVG) or SVG associated with a single ITA. This is a direct consequence of the limited number of patients requiring reoperation when two ITAs are used. Indeed, Lytle and colleagues [18] have demonstrated that the use of two ITAs instead of one decreases the number of cardiac-related events after 7 years. However, in the setting of angina recurrence and patent BITAs, cardiologists may be reluctant to refer their patients for repeat surgery because of the perceived associated morbidity and/or mortality using conventional techniques. This was well-illustrated in this series by the high number of preoperative angiograms performed (mean, 2.6). Often, redo CABG in this population is considered by the cardiologist as the last resort for the patients with incapacitating symptoms due to single right vessel disease, despite maximal medical therapy. Indeed, in a series of 36 patients reoperated on by conventional sternotomy with bilateral internal thoracic arteries in situ, Joyce and colleagues [19] reported a mortality of 11%. However, the small number of patients (3 of 36 vs 1 of 15) precludes us from drawing any robust conclusion despite the difference noticed between this series and our results (11% vs 6%).
In this series, we report the use of a third arterial conduit, the RGEA, in patients initially operated on using BITA grafts and thereafter requiring single-vessel revascularization of the inferior wall of the heart using a MIDCABG technique. The RGEA has been shown to be a good additional conduit for primary CABG [20–22]. Indeed, graft patency of the right gastroepiploic artery in conventional CABG has been shown to be superior to venous grafts, with early patency rates exceeding 90% in the largest series [20–22].
With these promising midterm results, and because of the incidence of saphenous vein graft occlusion in this young population (60 years mean age), we have now modified our policy for the use of the RGEA to revascularize all patients less than 75 years old, with a right coronary artery stenosis of greater than 70%. Moreover, if the RGEA's use is contraindicated, we would recommend, in this cohort of patients, to use another arterial graft such as the radial artery or the right internal mammary artery, used as a Y graft because of its theoretical superiority in terms of long-term patency compared to the saphenous vein graft.
Conclusion
Off-pump MIDCABG redo operation using the GEA is a helpful alternative to conventional CABG in patients with patent BITA. Further follow-up is required to ensure that long-term patency matches that of GEA grafts used in the conventional setting and that the advantages reported in terms of early mortality and morbidity are confirmed in larger numbers.
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Acknowledgments
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This study was supported by grant no. 3.4537.05 from the "Fond de la recherche scientifique médicale," Brussels, Belgium.
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Abstract
Introduction
