Gastroepiploic Artery Graft Research Articles

Severe stenosis of the superior mesenteric artery causing an acute coronary syndrome successfully treated by percutaneous angioplasty

Pedicled gastroepiploic artery (GEA) may be used as an arterial conduit in selected patients undergoing total arterial coronary bypass grafting [1]. Myocardial ischemia may result from spasm, occlusion, and stenosis of the graft [2]. The anastomosis site at distal right coronary artery (RCA) is reported to be the most common location for stenosis of pedicled GEA bypass graft. In this work, we describe a unique case, in which the celiac artery was totally occluded and collateralized by the superior mesenteric artery which was itself severely stenosed at its ostium. Lesions manifested as an acute coronary syndrome. The patient was treated by percutaneous angioplasty with stent placement at the ostial mesenteric artery. An 84-year-old woman was referred to our intensive care unit by the emergency department for a non ST elevation myocardial infarction; EKG showed a marked ST segment depression in the lateral and inferior leads (Fig. 1) and troponin T level was elevated at 2.4 mg/l. The patient has a known history of coronary artery bypass grafting (9 years prior to admission) with a GEA to the right coronary artery, left internal mammary artery to the left anterior descending and right mammary artery to the left circumflex. She has a severe peripheral artery disease with a known occlusion of the right internal carotid artery and a total occlusion of the lower abdominal aorta. Coronary angiogram was performed through a double radial access: all the native coronary arteries were totally occluded, both internal thoracic artery grafts were patent (Fig. 2a, b). A significant ostial stenosis of the left subclavian artery was noted (Fig. 2c). We were unable to selectively opacify the celiac artery which was totally occluded. It was completely collateralized by the superior mesenteric artery which was presenting a severe ostial stenosis (Fig. 2d). A patent GEA was observable on the late frames of the mesenteric artery sequences (Fig. 2e). Given the EKG aspect of ischemia in inferior and lateral leads, we assumed that the culprit lesion was the ostial stenosis of the mesenteric artery which was ultimately responsible for the vascular supply of all the inferior territory. Through the left radial access, a balloon-expandable stent was successfully implanted with excellent immediate angiographic results (Fig. 2f, g). Given the relative frailty of the patient and the difficulty in vascular access, we decided to treat during the same procedure the high-grade stenosis of the ostial left subclavian artery which could potentially alter the flow on the left mammary artery; hence, a self-expandable stent was successfully implanted (Fig. 2h). The immediate clinical evolution was favorable; however on day 4, the patient presented a massive stroke and unfortunately expired few hours later in the coronary care unit. The present report is the first, to our knowledge, to document an ACS caused by a severe stenosis of the mesenteric artery collateralizing totally occluded celiac and gastroepiploic arteries. Although the superiority of GEA grafts over the saphenous vein grafts has never been clearly established in the setting of surgical revascularization of the RCA [3], they have been used by some surgical teams when an allarterial bypass grafting was deemed suitable. Ischemic events related to pedicled GEA grafts have been classically linked to a disease progression in the S. Rekik (&) J. Brunet F. X. Hager G. Bayet L. Meille J. M. Quatre J. Sainsous Cardiovascular Department, Clinique Rhone Durance, Avignon, France e-mail: sofienerek@yahoo.fr

Right Gastroepiploic Artery Graft for Myocardial Revascularization: Prevalence of Atherosclerosis and Availability as a Conduit

We evaluated prevalence of atherosclerosis and availability of right gastroepiploic artery graft in patients undergoing coronary artery bypass graft surgery. Among the 1,579 patients who underwent isolated coronary artery bypass grafting between January 1999 and December 2008, we opened the peritoneum to examine the right gastroepiploic artery for use as a graft in 1,128 patients (71.4%). A computer-based patient database system was utilized for this retrospective study. Of 1,128 patients, 139 patients (12.3%) had atherosclerotic right gastroepiploic arteries at gross examination. Seventy-three of 139 atherosclerotic right gastroepiploic arteries had multiple or diffuse atherosclerotic lesions that precluded their use as a bypass graft; the remaining 66 right gastroepiploic arteries were used as a bypass graft including the atheromatous segment or after exclusion of the atherosclerotic segment. Another 60 nonatherosclerotic right gastroepiploic arteries were unavailable to use as a graft because of their short length, small caliber, and weak pulsation. Overall availability of the right gastroepiploic arteries as a graft was 88.2% (995 of 1,128). Multivariable logistic regression analysis showed older age (≥65 years; p < 0.001), insulin-treated diabetes mellitus (p = 0.001), and chronic renal failure (p < 0.001) as independent risk factors for atherosclerosis. The prevalence of atherosclerosis and availability of the right gastroepiploic artery graft in patients undergoing isolated coronary artery bypass grafting was 12.3% and 88.2%, respectively. Older age (≥65 years), insulin-treated diabetes mellitus, and chronic renal failure were identified as independent predictors for the atherosclerotic right gastroepiploic artery.

Intrapericardial Diaphragmatic Hernia after Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery Graft: Report of a Case

Surgeons should be aware of diaphragmatic hernia in obese patients who have undergone coronary artery bypass grafting (CABG) using a gastroepiploic artery graft (GEA), even if the antegastric route is utilized.We report a case of diaphragmatic hernia, which occurred 88 months after initial CABG. A 64-year-old obese man underwent surgical repair of a diaphragmatic hernia. At initial surgery, the diaphragm was incised vertically and re-sutured, leaving a route for GEA graft. Both the stomach and the lateral segment of the liver were dislocated in the pericardial space. The diaphragmatic defect was closed with a polytetrafluoroethylene patch.

En-Bloc Free Gastroepiploic Artery Graft Provides a Good Long-Term Patency Rate

For coronary artery bypass grafting, the use of free gastroepiploic artery is unpopular because of its tendency to vasospasm. We assessed the en-bloc free gastroepiploic artery graft, which has the gastroepiploic vein anastomosed to the right atrial appendage to prevent graft spasm, and compared it to the skeletonized free gastroepiploic artery graft. A retrospective review was conducted in 57 patients who received en-bloc grafts and 29 who had skeletonized grafts. Kaplan-Meier analysis demonstrated the superiority of the en-bloc free gastroepiploic artery graft with an 80-month patency rate of 96.6% compared to 66.7% with skeletonized grafts. We selected 13 cases from each group, using propensity-score matching, and compared the long-term patency rates. Propensity-score matched analysis showed 80-month patency rates of 100% for en-bloc grafts and 60% for skeletonized grafts. Coronary artery bypass using free gastroepiploic artery grafts with venous drainage seems to provide good long-term results.

Graft Selection and One-Year Patency Rates in Patients Undergoing Coronary Artery Bypass Grafting

The aim of this study was to assess the angiographic patency rates of grafts used for coronary artery bypass surgery. We reviewed the records of 930 patients who underwent isolated coronary artery bypass grafting between September 2004 and June 2009. Of these patients, 95.1% underwent off-pump coronary artery bypass grafting. Early and 1-year angiographic patency rates of grafts were assessed. Mean anastomoses per patient were 4.0 +/- 1.3. Operative mortality was 0.5%. Stroke occurred in 2.2% of patients, and 1.3% had mediastinitis. Early and 1-year patency rate of total grafts was 97.4% and 87.5%, respectively. One-year patency rate of the left internal thoracic artery, right internal thoracic artery, radial artery, gastroepiploic artery, and saphenous vein graft was 96.1%, 92.0%, 69.5%, 81.4%, and 82.6%, respectively. One-year patency rates of in situ and free right internal artery graft were not significantly different (p = 0.13). One-year patency rate of the radial artery was significantly worse than that of the free right internal thoracic artery graft (p < 0.01) and saphenous vein graft (p < 0.01). Multiple coronary arterial revascularizations in various combinations of grafts were clinically safe and effective for isolated coronary artery bypass surgery. Bilateral internal thoracic artery grafting for the left coronary artery system was the most reliable strategy as shown by angiographic patency rates.

Right coronary artery chronic total occlusion revascularization by knuckle technique through right gastroepiploic artery graft

Sirs:Angina pectoris following bypass surgery is caused bygraft failure or new lesions developing in the native coro-nary artery. Right gastroepiploic artery (RGEA) has beenshown to have a good short- and long-term patency whenanastomosed to the right coronary artery (RCA). Long-term patency is 80–90% at 5 years; however, it decreasesto approximately 62% at 10 years [1].Many reports suggest that successful revascularizationof chronic total occlusion (CTO) subtending viable myo-cardium determines a more favorable long-term outcomewith survival enhancement and improvement in quality oflife [2, 3].We present a case of RCA CTO recanalization usingretrograde approach through RGEA graft.Case reportA 64-year-old man ex smoker with hypercholesterolemia,type II diabetes mellitus, mild hypertension underwentcoronary artery bypass graft (CABG) surgery for anteriormyocardial infarction in 1997 with left internal mammaryartery (LIMA) on left anterior descending (LAD) andRGEA on posterior descending artery (PDA). Since 2003the patient referred onset of angina at medium workload;he performed an exercising test which was interrupted at75 W for V3–V6 down-sloping ST depression and non-sustained ventricular tachycardia. For this reason thepatient was referred for a new coronary angiography(CAG) which showed: LIMA patent, distal LAD withsevere stenosis, RCA proximal occlusion, RGEA patentwith disease at the anastomosis and in native distal RCA(crux) (Fig. 1a–b). The patient was referred for a newCABG in 2004; however, he refused this treatment and hestarted optimal medical therapy. After 5 years, due tosymptoms worsening, the patient underwent CAG (May2009) which showed a comparable angiographic pattern tothe previous one. Thus, the patient underwent a stressmyocardial scintigraphy which showed severe reversibleinfero-lateral hypoperfusion with a normal left ventricularfunction. Thereafter it was decided to attempt RCA per-cutaneous revascularization in June 2009.Unfractionated heparin (5,000 units intravenously) wasadministered. A 7 French Amplatz left and a 7 FrenchJudking right guiding catheter were used to engage RCAostium and RGEA graft, respectively. Contrast meaninjection from RGEA confirmed severe disease at theanastomosis and distally native RCA. The lesion was firstapproached by antegrade with a soft-tapered polymericguidewire (Fielder XT, Asahi) and a microcatheter (Fine-cross, Terumo) which was advanced up to the mid-RCA.As this guidewire was not able to progress any further, itwas exchanged using the microcatheter with an interme-diate-stiffness one (Medium guidewire, Asahi). The Med-ium guidewire was able to advance up to the mid-distal partof the vessel where it stopped due to severe calcifications.Thus, a soft-tapered polymeric guidewire (Fielder XT,Asahi) was inserted with a Corsair microcatheter (Asahi)through RGEA by retrograde. This wire got through thesevere disease at the anastomosis; however, it stuck in the

Rerouting revascularization of the living right gastroepiploic artery graft in a patient with de novo gastric cancer

We present a case in which a redo patient in whom advanced gastric cancer was detected after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA), and in which re-grafting to the distal RGEA using the right internal thoracic artery (RITA) was performed. To minimize the surgical invasion before gastrectomy, we performed a thoracoscopic RITA harvest and small subxyphoid incision. A month later, distal gastrectomy was carried out and no complications occurred during the operation.

Preserved Blood Flow in the Composite Right Gastroepiploic Artery Graft During Norepinephrine Infusion

We examined the effect of norepinephrine infusion on blood flow in Y-composite right gastroepiploic artery grafts after off-pump coronary artery bypass grafting. Enrolled were 28 patients who were scheduled for revascularization with a Y-composite graft (end-to-side anastomosis of the right gastroepiploic artery to the in situ left internal thoracic artery graft). After all planned anastomoses were completed in each patient, blood flow in the right gastroepiploic artery composite graft and the internal thoracic artery graft (proximal and distal to the right gastroepiploic artery graft) was measured before and after continuous norepinephrine infusion. Blood flow in right gastroepiploic artery (26.4 +/- 15.8 vs 33.8 +/- 18.0 mL/min, p = 0.0004), proximal left internal thoracic artery (47.5 +/- 21.2 vs 61.6 +/- 23.4 mL/min, p < 0.0001), and distal left internal thoracic artery (20.1 +/- 12.1 vs 26.8 +/- 14.6 mL/min, p < 0.0001) grafts increased after norepinephrine infusion. In addition, the proportion of blood flow in right gastroepiploic artery grafts based on the blood flow in proximal left internal thoracic artery grafts was preserved (57.2% +/- 24.7% vs 55.1% +/- 25.6%, p = 0.607). Blood flow in right gastroepiploic artery composite grafts after off-pump coronary artery bypass grafting was preserved during norepinephrine infusion.

Intraoperative assessment of coronary bypass graft to posterior descending artery by means of transesophageal echocardiography

Intraoperative transesophageal echocardiography (TEE) assessment of coronary artery graft anastomosed to posterior descending artery (PDA) was evaluated. Twenty-one patients with a saphenous vein (SV) graft (n=17) or right gastroepiploic artery (RGEA) graft (n=4) anastomosed to the PDA were examined. In the transgastric mid short-axis view, the graft was depicted as an echo-free zone between the right ventricle and diaphragm. The depth, diameter, angle for Doppler measurement, and angle-corrected blood flow velocity were determined. The graft was visualized in 20 cases (95.2%). The diameter of the SV graft was 3.0-6.5 mm (mean 4.0 mm), while that of RGEA graft was 2.2-2.9 mm (mean 2.5 mm), at the depth of 1.2-4.4 cm (mean 2.4 mm) with incident angle of 14-57 degrees (mean 38.6 degrees ). Blood flow was detected in 17 cases but was difficult to detect in three cases (velocity <10 cm/s). Postoperative coronary angiography showed patent graft in 16 of former cases (one case of operative death excluded) but occluded graft in all of latter cases. Intraoperative TEE assessment was feasible nearly consistently. Diastolic blood flow velocity <10 cm/s suggests an early occlusion of the graft.

Bilateral internal thoracic artery on the left side: A propensity score–matched study of impact of the third conduit on the right side

This study was undertaken to evaluate long-term results of bilateral internal thoracic artery grafting with saphenous vein or another arterial conduit as the third conduit. From September 1991 to December 2002, a total of 1015 patients underwent first isolated coronary artery bypass grafting for triple-vessel disease, with bilateral internal thoracic artery plus saphenous vein in 643 cases and bilateral internal thoracic artery plus arterial conduit in 372. A nonparsimonious regression model was built to determine propensity score, then sample matching (saphenous vein vs arterial conduit) was performed to select 885 patients (590 with saphenous vein, 295 with arterial conduit). Groups had similar preoperative and operative characteristics. Eight-year freedoms from cardiac death were significantly higher when saphenous vein was used (98.6% +/- 0.5% with saphenous vein vs 95.3% +/- 1.3% with arterial conduit, P = .009), but this difference was related exclusively to right gastroepiploic artery grafting (94.5% +/- 1.6% vs saphenous vein, P = .004). This difference disappeared for radial artery grafting (97.6% +/- 1.6% vs saphenous vein, P = .492). Cox analysis confirmed that supplementary gastroepiploic artery was an independent variable for lower freedoms from all-cause mortality and from cardiac death. Presence of high-degree stenosis (80%) appeared to influence this result. In patients with triple-vessel disease undergoing first isolated coronary artery bypass grafting, supplementary venous grafts seem to provide more stability than gastroepiploic artery, which may even impair long-term outcome.

Comparison of saphenous vein graft versus right gastroepiploic artery to revascularize the right coronary artery: A prospective randomized clinical, functional, and angiographic midterm evaluation

Despite its theoretic advantage over saphenous vein grafts, the right gastroepiploic artery graft has not been accepted as the ideal conduit to revascularize the right coronary artery. We therefore prospectively randomized these 2 grafts types to compare their clinical, functional, and angiographic evolution at 6 months and 3 years. From 2003 to 2006, 1397 consecutive patients underwent isolated revascularization at the University of Louvain Medical School. Of this group, 370 patients met the inclusion criteria for randomization and 66% of those were randomized. The right coronary artery was revascularized with saphenous vein grafts in 116 patients and with right gastroepiploic arteries in 122 patients. All patients underwent angiographic control 6 months postoperatively. The end points were major adverse cerebrocardiovascular events and proportion of grafts patent or functional at follow-up angiography. There were no significant differences between the 2 groups in terms of hospital events. At follow-up there was no significant difference in major adverse cerebrocardiovascular events between the 2 groups. At the 6-month angiographic follow-up, 91% of the anastomoses in the right gastroepiploic artery group and 95% of the anastomoses in the saphenous vein graft group were controlled patent (P = .92). In nonoccluded right coronary arteries, the proportion of patent grafts was significantly lower and the proportion of nonfunctioning grafts was significantly higher in the right gastroepiploic artery group than in the saphenous vein graft group. There were no significant patency or major adverse cerebrocardiovascular events rate differences between the 2 groups; however, the number of functional grafts was significantly higher in the saphenous vein graft group. Careful selection of the coronary target is mandatory to obtain good results in gastroepiploic artery grafting.

Transplantation of the Free Gastroepiploic Artery Graft for Myocardial Revascularization: Long-Term Clinical and Angiographic Results

Use of the free gastroepiploic artery (GEA) graft for coronary revascularization is not very popular because of its tendency to vasospasm. We hypothesize that the cause of free GEA spasm is graft damage caused by an interruption of venous drainage from the graft. To overcome this problem, we anastomosed the accompanied gastroepiploic vein to the right atrial appendage simultaneously with the GEA grafting in the aortocoronary position. We here assess the clinical result and the angiographic patency of the free GEA graft in our method in the late postoperative period. Between January 1997 and April 2001, 57 patients underwent coronary artery grafting with a free GEA using our method. A total of 169 distal anastomoses (average 2.96) were constructed. The free GEA grafts were anastomosed to the main right coronary artery in 26 patients, right coronary artery branch in 27, left anterior descending artery in 1 patient, high lateral branch in 2 patients, and circumflex branch in 2. The mean clinical follow-up is 77 months (range, 35 to 110) in 57 cases, and the angiographic follow-up averages 77 months (range, 37 to 110) in 46 cases. There was no cardiac death, and all patients were in Canadian Cardiovascular Society class II or less. The mean 77-month patency rate of the free GEA in our method was 95.7%. The patency rates of internal thoracic artery, radial artery, and saphenous vein graft in the same period were respectively 93.2%, 100%, and 81.3%. Free GEA grafting with venous drainage for myocardial revascularization provided excellent long-term performance.

Invited Commentary

There are enthusiasts for gastroepiploic artery (GEA) coronary bypass grafting on three continents, and a few surgeons have reported large experiences using this conduit, but 10-year patency is disappointing. Early patency of the free GEA has also been inferior, but the experience is small and early in the use of this conduit (ie, 3 of 4 reports from 1990 or before and 1 of 4 from 1993). The GEA graft has been attractive as an in situ conduit and used by some to achieve all arterial revascularization without aortic anastomosis when combined with the in situ internal thoracic arteries (ITAs). Despite this utility, there are several limitations and concerns. The GEA is less consistent in size than the ITA and the radial artery (RA), and its in-flow via the celiac axis may be compromised by atherosclerosis. The GEA also diminishes in diameter along its length to a greater degree than the ITA or RA, so that its useful length may be limited. Routing through the diaphragm is relatively straightforward and has not been identified as a cause of failure, but it does present the concern of angulation or kinking and the challenge of optimal placement to achieve a parallel approach to the target without compromising conduit length. Having a totally muscular media, such as the RA, it is more prone to spasm than the ITA, will usually benefit from topical or intraluminal vasodilators, or both, and it is vulnerable to competitive coronary flow. Also subsequent laparotomy may result in injury to the conduit. Initial harvesting was done with a bulky pedicle of omentum with a subsequent trend toward semi or true skeletonization, which is more attractive. The present report uses a free graft with a bulky pedicle and anastomosis of the gastroepiploic vein to the right atrial appendage. Most impressive is the 95.7% patency at a mean of 77 months in 46 patients. I believe the improved patency is a consequence of good surgical technique and free grafting that improves in-flow and addresses many of the previously mentioned concerns. The authors [1Eda T. Matsuura A. Miyahara K. et al.Transplantation of the free gastroepiploic artery graft for myocardial revascularization: long-term clinical and angiographic results.Ann Thorac Surg. 2008; 85: 880-884Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] suggest that venous drainage is the reason for improved patency, but they do not provide a control group. Historically, it has been suggested that the free ITA graft would be compromised without venous anastomosis but patency for it, the RA and the inferior epigastric artery disprove that viewpoint. The authors experience warrants consideration of preferential use of the GEA as a free graft from the aorta or the ITA without venous anastomosis and with a lean pedicle or skeletonized conduit. Transplantation of the Free Gastroepiploic Artery Graft for Myocardial Revascularization: Long-Term Clinical and Angiographic ResultsThe Annals of Thoracic SurgeryVol. 85Issue 3PreviewUse of the free gastroepiploic artery (GEA) graft for coronary revascularization is not very popular because of its tendency to vasospasm. We hypothesize that the cause of free GEA spasm is graft damage caused by an interruption of venous drainage from the graft. To overcome this problem, we anastomosed the accompanied gastroepiploic vein to the right atrial appendage simultaneously with the GEA grafting in the aortocoronary position. We here assess the clinical result and the angiographic patency of the free GEA graft in our method in the late postoperative period. Full-Text PDF

Angiographic Predictors of 6-Month Patency of Bypass Grafts Implanted to the Right Coronary Artery: A Prospective Randomized Comparison of Gastroepiploic Artery and Saphenous Vein Grafts

The purpose of this study was to define the pre-operative angiographic variables that could influence graft patency and flow pattern. Saphenous vein grafts (SVG) and pedicled right gastroepiploic artery (RGEA) grafts are routinely used to revascularize the right coronary artery (RCA). Little is known about the predictive value of objective pre-operative angiographic parameters on the 6-month graft patency and on the interest of these parameters to select the optimal graft material in individual cases. We prospectively enrolled 172 consecutive patient candidates for coronary revascularization. Revascularization of the RCA was randomly performed with SVG in 82 patients or with the RGEA in 90 patients. Both groups were comparable with respect to all pre-operative continuous and discrete variable and risk factors. All patients underwent a systematic angiographic control 6 months after surgery. Pre-operative angiographic parameters included minimal lumen diameter (MLD), percent stenosis and reference diameter of the RCA measured by quantitative angiography (CAAS II system, Pie Medical, Maastricht, the Netherlands), location of the stenosis, run off of the RCA, and regional wall motion of the revascularized territory. A significant difference in the distribution of flow patterns was observed between SVG and RGEA. In multivariate analysis, graft-dependent flow pattern was significantly associated with both MLD and percent stenosis of the RCA in the RGEA group but with percent stenosis only in the SVG group. In the RGEA group, the proportion of patent grafts was higher when MLD was below a threshold value lying in the third MLD quartile (0.77 to 1.40 mm). Pre-operative angiography predicts graft patency in RGEA, whereas the flow pattern in SVG is significantly less influenced by quantitative angiographic parameters.

Twenty Years Experience With the Gastroepiploic Artery Graft for CABG

To improve the longterm outcome after CABG, several strategies have been used using arterial conduits. Our 20 years experience with the right gastroepiploic artery (GEA) graft was evaluated. In 1352 patients having CABG with the GEA graft, (1092 men, mean 63 years, 99% multivessel disease, and mean EF 0.51), internal thoracic artery, saphenous vein, and radial artery grafts were concomitantly used in 1312 (97%), 783 (58%), and 128 (8%) patients, respectively. The mean number of distal anastomoses was 3.1, and 2.4 coronary arteries were bypassed with arterial grafts. The sites for GEA grafting were 70 anterior descending, 268 circumflex, and 1089 right coronary arteries. The operative mortality was 1.26%. In 1118 follow-up patients (82.6%), 5, 10, and 15 years survival rates were 91.7%, 81.4%, and 71.3%, and the cardiac death-free survival rates were 95.8%, 91.7%, and 88.6%, respectively. The cumulative patency rate of the GEA graft was 97.1% at 1 month, 92.3% at 1 year, 85.5% at 5 years, and 66.5% at 10 years, respectively. In 172 skeletonized GEA grafts with 233 distal anastomoses, the patency rate at immediate, 1, and 4 years after surgery was 97.6%, 92.9%, and 86.4%, respectively. In 124 patients with late (5 to 17 years) restudy, patency rate was 96% (114/119) in the left internal thoracic artery, 87% (108/124) in GEA, and 68% (67/98) in saphenous vein grafts. New stenosis was uncommon in GEA. The GEA graft is a safe and effective arterial conduit for CABG.

Spontaneous Restoration of Patency in the Free Gastroepiploic Artery Graft: The Living Transplanted Vascular System for Coronary Revascularization

We report an incidence of coronary revascularization with the gastroepiploic artery in which angiography demonstrated patency at 1 month, severe narrowing at 1 year, and restoration of patency associated with progression of proximal coronary disease at 8 years. This report documents the reversibility of the free gastroepiploic artery.

Anesthesia for pancreatoduodenectomy in a patient with history of coronary artery bypass graft surgery: determination of optimal surgical management by the graft clamping test

We report a case of a 72-year-old man undergoing pancreatoduodenectomy, who had a history of coronary artery bypass graft surgery using the right gastroepiploic artery. We intraoperatively used the graft clamping test, which was assessed via electrocardiography and transesophageal echocardiography, to verify patency of the right gastroepiploic artery graft. Because the graft clamping test was positive, first, we interposed the saphenous vein graft between the splenic artery and right coronary artery. The abdominal surgery was then successfully performed without any cardiac complications. In such a complicated case, anesthesiologists who are responsible for assessment of the graft clamping test play a crucial role in determining the optimal surgical procedure.

Invited commentary

Bilateral internal thoracic artery grafting (BITA) to the left anterior descending and circumflex coronary arteries offers the best long-term survival (after 10 years) and the lowest rates of reintervention in patients undergoing coronary artery bypass grafting surgery. The best graft for the right coronary artery in patients with three-vessel disease has not been confirmed. The right gastroepiploic artery (GEA), the radial artery, saphenous vein graft (SVG), and composite radial artery or internal thoracic artery grafts are the most frequent choices. Esaki and colleagues [1Esaki J. Koshiji T. Okamoto M. Tsukashita M. Ikuno T. Sakata R. Gastroepiploic artery grafting does not improve the late outcome in patients with bilateral internal thoracic artery grafting.Ann Thorac Surg. 2007; 83: 1024-1029Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar] performed a retrospective study comparing 311 patients with three-vessel coronary artery disease who had BITA grafting to the left anterior descending and circumflex coronary arteries. The GEA was used in 99 patients. The SVG was used in 212 patients to bypass the right coronary artery. Although 7-year survival rates were excellent, no statistical difference in early and 7-year survival and freedom from cardiac events, reintervention, angina, or myocardial infarction was found between the two groups. Reasons offered by the authors for lack of improvement in the GEA group are that the long-term patency in the GEA is similar to the SVG, there are too few GEA patients, and the follow-up period is too short. I would agree that the follow-up period should be longer to make a definite decision on any distinct advantages to using the GEA. Not mentioned in the article is the incidence of suboptimal anastomoses, competition of flow, and new coronary artery lesions discovered on routine early or later coronary artery angiograms. Early correction of these causes of potential graft failure with the exception of competition of flow should improve long-term patency and outcomes, particularly in patients with all arterial coronary bypass grafts. These factors may have been helpful in obtaining the excellent early patency reported with the internal thoracic artery grafts. Gastroepiploic Artery Grafting Does Not Improve the Late Outcome in Patients With Bilateral Internal Thoracic Artery GraftingThe Annals of Thoracic SurgeryVol. 83Issue 3PreviewBilateral internal thoracic artery grafting in coronary artery bypass surgery has a better long-term outcome than single internal thoracic artery grafting. However, the efficacy of gastroepiploic artery (GEA) grafting in addition to bilateral internal thoracic artery grafting is still not well-established. Full-Text PDF

Gastroepiploic Artery Grafting Does Not Improve the Late Outcome in Patients With Bilateral Internal Thoracic Artery Grafting

Bilateral internal thoracic artery grafting in coronary artery bypass surgery has a better long-term outcome than single internal thoracic artery grafting. However, the efficacy of gastroepiploic artery (GEA) grafting in addition to bilateral internal thoracic artery grafting is still not well-established. From 1989 to 1999, 311 patients underwent coronary artery bypass grafting using in situ bilateral internal thoracic arteries anastomosed to the left coronary arteries and either an in situ GEA or a saphenous vein graft (SVG) anastomosed to the right coronary artery. Ninety-nine patients using the in situ GEA (GEA group) were compared with 212 patients using the SVG (SVG group) anastomsed to the right coronary artery. Young patients and patients with hyperlipidemia were more prevalent in the GEA group. The seven-year survival rate in the GEA group and the SVG group were 94.7% and 87.2%, respectively (p = 0.068). In a multivariate analysis, the age, renal failure, and a low ejection fraction (<0.40) were all significant predictors of survival. The GEA was not a significant predictor. The seven-year freedom rates from cardiac events were similar in both groups (GEA group, 76.5%; SVG group, 78.6%; p = 0.455). The seven-year freedom rates from recurrent angina were also similar between the groups (GEA group, 85.3%; SVG group, 88.8%; p = 0.700). In comparison with SVG grafting, GEA grafting to the right coronary artery did not significantly improve the late outcomes in patients with bilateral internal thoracic artery grafting.

Midterm Results for Use of the Skeletonized Gastroepiploic Artery Graft in Coronary Artery Bypass

To improve the long-term results of coronary artery bypass grafting (CABG), several arterial conduits have been used, including the skeletonized right gastroepiploic artery (GEA) graft. The skeletonized GEA graft was used for CABG in 223 patients over a 6-year period (208 males, 15 females, mean age 64 years). 1-, 2- and 3-vessel and left main trunk disease was noted in 1, 28, 122 and 72 patients, respectively. Internal thoracic artery, radial artery and saphenous vein grafts were concomitantly used in 217 (97%), 73 (33%) and 41 (18%) patients, respectively, and the mean number of grafts was 3.5. The sites of GEA grafting were 1 anterior descending, 10 diagonal, 97 circumflex, and 185 right coronary arteries, with 154 single in-situ, 33 free and 36 composite grafts, including 56 sequential grafts. There was 1 (0.4%) operative death. New Q wave was noted in 2 (0.9%) patients. Postoperative angiography revealed 97.6% early postoperative (within 1 month) and 91.5% midterm (mean 27 months) patency rates for GEA grafts. The cumulative 4-year patency rate of the skeletonized GEA graft was 86.4%. The skeletonized GEA is a safe and effective arterial conduit for CABG.