10.5 Is bilateral internal mammary and gastroepiploic artery bypass grafting a reasonable routine technique?

Abstract

Experience with 39 patients (32 men, 7 women) undergoing coronary artery bypass grafting with the right gastroepiploic artery (RGEA) is reported. Indications initially included poor-quality or absent saphenous vein, ascending aortic atherosclerosis, and repeat coronary artery bypass grafting. The average number of grafts per patient was 4.10. Arteries bypassed were the posterior descending (22 patients), right coronary (12), diagonal (5), and marginal (4). Distal RGEA internal diameters of all grafts measured 1.5 to 3.25 mm (average diameter, 2.14 mm). Pedicled graft lengths measured 18 to 30 cm (average length, 23.7 cm), and free grafts, 8 to 24 cm (average length, 17.7 cm). In 6 patients, no vein grafts were used, and in all patients, at least one internal mammary artery graft was placed. Early postoperative cardiac catheterization (19 pedicled and ten free grafts) in 29 patients revealed all grafts to be patent without a kink or twist, but three of these free RGEA grafts had vasospasm. Advantages of RGEA grafts are as follows: (1) it is a third arterial conduit with artery-artery anastomoses of comparable sizes; (2) a shorter leg incision or no leg incision is necessary; (3) it can be harvested simultaneously with the internal mammary artery and the saphenous vein; (4) the proximal anastomosis (free grafts) is easy; (5) its use avoids bilateral internal mammary artery grafts in patients at high risk for sternal infection; and (6) atherosclerotic ascending aortas are not clamped. Subintimal hyperplasia and atherosclerosis of RGEA grafts are unlikely. There are several disadvantages to the RGEA grafts: (1) the abdominal cavity must be entered; (2) the graft is not available after a gastric operation; (3) there is the possibility of graft damage with future abdominal procedures; (4) operating time is longer; and (5) at present, long-term patency and adequacy of flow are uncertain. Some important technical features of the operation include: (1) careful pericardial entry of pedicled grafts; (2) multiple tacking sutures for RGEA grafts; (3) marking the pedicle to avoid twists or kinks; (4) large RGEA branch ligation rather than clipping or cautery; and (5) intraluminal infusion of dilute papaverine hydrochloride to dilate the grafts before cardiopulmonary bypass.