Gastroepiploic Artery Graft Research Articles

Searching for the second best graft for coronary artery bypass surgery: a network meta-analysis of randomized controlled trials

There is a lack of unequivocal evidence basis for selecting the best second conduit in coronary artery bypass grafting (CABG). We thus aimed to perform head-to-head relative effect estimate on angiographic outcomes for second conduits, including the right internal mammary artery (RIMA), radial artery (RA), right gastroepiploic artery (RGEA) and saphenous vein graft (SVG) by means of network meta-analysis of randomized controlled trials (RCTs). Databases were searched for RCTs comparing angiographic outcomes (≥4 weeks) of second conduits in CABG. Odds ratios (95% confidence intervals) were computed with Markov Chain Monte Carlo simulation. A total of nine RCTs were identified, including 2780 patients and 1620 angiographic results available for analysis to compare RIMA (n=145) versus RA (n=871) versus RGEA (n=92) versus SVG (n=845). The mean time to angiographic follow-up ranged from 1 to 7.7 years. An SVG was significantly associated with a 4-fold (1.67-16.00) and 3-fold (0.78-22.20) increased risk of late (≥4 years) functional graft occlusion when compared with the RIMA and RA, respectively. A RIMA was associated with a non-significant 27% absolute risk reduction for functional graft occlusion when compared with the RA. The present network meta-analysis consistently demonstrated an angiographic superiority of RIMA and RA over SVG. The RIMA is expected to achieve a better patency rate than the RA, but further studies are needed.

Significance of Preoperative Evaluation of the Right Gastroepiploic Artery Graft to the Coronary Artery in Patients Undergoing Abdominal Surgery

A major concern with the use of the right gastroepiploic artery (RGEA) as the graft for coronary artery bypass grafting (CABG) is the potential for injury, which can result in critical myocardial ischemia during future abdominal surgery. We examined the availability of preoperative image evaluation, preoperative recognition of the RGEA graft, and operative findings such as graft identification, graft injury, and cardiac events in 11 patients who underwent abdominal surgery after CABG using the RGEA as the graft. Prior to the abdominal surgery, contrast-enhanced computed tomography (CT) was performed in all 11 patients, while coronary angiography or three-dimensional CT angiography was performed in five patients. We detected the RGEA graft retrospectively in nine of ten patients in whom the images from contrast-enhanced CT were still available. Among the seven patients whose RGEA grafts were in the operative field, the RGEA graft was identified in five patients, while the RGEA graft was not identified in the remaining two patients because of adhesions. There were no intraoperative cardiac events in any of the 11 patients. It is important to determine whether an RGEA graft is present when repeat laparotomy is required after CABG. In cases where an RGEA graft is present, it is essential to evaluate the patency and location of the graft since this will be crucial for planning the reoperation strategy. Preoperative recognition and evaluation of the RGEA graft can help avoid graft injury, even if the graft cannot be detected intraoperatively.

27 years experience with the gastroepilopic artery graft in CABG

To improve the long-term outcome after CABG, several strategies have been used using arterial conduits.In 27 years experience with the right gastroepiploic artery (GEA) graft, 1552 patients having CABG with the GEA graft, (1142 men, mean 64 years, 99% multivessel disease, and mean EF 0.51), internal thoracic artery, saphenous vein, and radial artery grafts were concomitantly used in 1505 (97%), 853 (55%), and 130 (9%) patients, respectively. The mean number of distal anastomoses was 3.2, and 2.4 coronary arteries were bypassed with arterial grafts. The sites for GEA grafting were 70 anterior descending, 318 circumflex, and 1239 right coronary arteries. The operative mortality was 1.26%. In 1118 follow-up patients (72.0%), 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 98.5% at 1 month, 93.7% at 1 year, 86.2% at 5 years, and70.2% at 10 years, respectively. In 372 skeletonized GEA grafts with 452 distal anastomoses, thepatency rate at immediate, 1, and 5 years after surgery was 98.6%, 94.9%, and 88.4%, respectively. In conclusion the GEA graft is a safe and effective arterial conduit for CABG.

Gastroepiploic artery graft in coronary artery bypass grafting.

The right gastroepiploic artery (GEA) has been recognized as a suitable and reliable conduit for coronary bypass surgery. From a sizable number of experiences, we know the use of this artery does not increase surgical risk, and no gastric ischemia nor abdominal complications occur with takedown of the GEA. This artery undergoes less significant arteriosclerosis and demonstrates physiological adaptability as seen in the internal thoracic artery (ITA). From our experience with over 1,500 GEA grafts, the operative mortality was 1.26%, and 5-, 10-, and 15-year survival rates were 91.7%, 81.4%, and 71.3% respectively, while the cardiac death-free survival rates were 95.8%, 91.7%, and 88.6%, respectively. The cumulative patency rate of the GEA graft was 98.5% at 1 month, 93.7% at 1 year, 86.2% at 5 years, and 70.2% at 10 years. The GEA graft is a safe and effective arterial conduit for coronary artery bypass grafting (CABG).

Early and Long-Term Patency of In Situ Skeletonized Gastroepiploic Artery After Off-Pump Coronary Artery Bypass Graft Surgery

There is at present no accurate figure for the long-term patency rate of the skeletonized gastroepiploic artery (GEA). From January 2002 to July 2012, 956 consecutive patients underwent isolated off-pump coronary artery bypass graft (OPCABG) surgery at our institution. Of these, the 424 who underwent GEA grafting and postoperative GEA graft evaluation were the subjects of the present study. Of these 424 subjects, 155 (36.6%) underwent long-term outpatient evaluation using multidetector computed tomography angiography. No patient was converted from off pump to on pump surgery. Overall 30-day mortality was 0.5% (2 of 424). The overall early (4 to 21 days after surgery) patency rate of the skeletonized GEA was 98.2% (599 of 610 anastomoses). A total of 215 GEA anastomoses, including 55 sequential bypasses, were followed for long-term evaluation, of which 12, including three sequential bypasses, were found to be occluded. The overall patency rate in skeletonized GEA grafting over a mean follow-up period of 73 months was 94.4% (203 of 215). The cumulative patency rate of the skeletonized GEA was 97.8% at 30 days, 96.7% at 1 year, 96.0% at 3 years, 94.7% at 5 years, and 90.2% at 8 years after surgery. Multivariate Cox proportional hazard regression analysis showed that target vessel stenosis (p = 0.008, hazard ratio 0.086, 95% confidence interval: 0.014 to 0.53) was the only independent predictor of late graft occlusion. We demonstrated an accurate long-term patency rate for the skeletonized GEA superior to that for pedicled GEA or saphenous vein graft. A low-grade degree of target vessel stenosis was the only risk factor for late GEA occlusion.

Pancreaticoduodenectomy after coronary artery bypass grafting with use of an in situ right gastroepiploic artery graft

Nowadays more old and comorbid patients, such as patients with a history of multiple coronary artery bypass grafting (CABG), are surgical candidates for pancreaticoduodenectomy. Harvesting of the right gastroepiploic artery (RGEA) is one of the most commonly used methods when multiple CABGs are required. We report a case of pancreaticoduodenectomy performed in a patient who had the RGEA used as an in situ graft for CABG. The RGEA was successfully preserved, with an uneventful postoperative course.

The Right Gastroepiploic Artery: Anatomical Study on 100 Cadaveric Dissections.

The gastroepiploic artery (GEA) with the greater omentum is known for its high quality as a vascular graft and its resistance to infection when used to perform bypass, free‐flap or flow‐through flap.Many authors have studied this anatomical unit, but a number of questions remain undiscussed.The aim of this anatomical study was to evaluate the diameter and length of the GEA graft and its omental branches and to assess the feasibility of the epiploic flow‐through flap.MethodsWe performed 100 cadaveric dissections.In 70 fresh cadavers we carried out dissections of GEA and of the greater omentum. Transillumination technique was helpful to identify all branches of GEA.In the other 30 cadavers, prepared with Winkler solution, we injected barium sulfate with colored latex. After four days we harvested the artery with the omentum and a digital radiography was performed in order to report measures of lengths and internal diameters.The diameter of GEA at its origin was 2.9 mm (2.7–3.4 mm). Its length was 245 mm (230–260 mm).ConclusionThe anatomical unit based on GEA defines a relatively long arterial graft and a reliable omental flap for vascularization. Our dissection data confirm the anatomical feasibility in all cases and define the limits. This graft can be useful in patients requiring revascularization combined with coverage of tissue loss.

Denervation of gastroepiploic artery graft can reduce vasospasm

The right gastroepiploic artery is useful as an in situ arterial graft for coronary artery bypass grafting. However, the gastroepiploic artery is more likely to cause vasospasms compared with the internal thoracic artery. We hypothesized that the cause of the spasms is the stimulation of the periarterial sympathetic nerve, because the gastroepiploic artery is classified as a muscular artery. In this study, we examined whether the spasm is reduced by removing the periarterial sympathetic nerve. Unused parts of the gastroepiploic artery were obtained from patients who underwent coronary artery bypass grafting. The vessel was cut into 2 segments, and they were assigned to control (N+) and denervation (N-) groups. The periarterial nerve was microscopically removed from the vessels of the N- group. The vessels in both groups were investigated by hematoxylin-eosin or immunohistochemical staining, and they were stimulated by electrical field stimulation with serial frequency for isometric tension measurement. Histologic analyses revealed that periarterial connective tissues including neuropeptide Y were removed to expose the external elastic membrane in the N- vessel, whereas they were preserved in N+. The mean contraction by electrical field stimulation with serial frequency was consistently lower in N- than in N+ (P<.05 at 20 and 50 Hz; n=8 each). Endothelium-dependent relaxation and contractile function of the smooth muscle were similar in both groups. The removal of the periarterial sympathetic nerve from the human gastroepiploic artery reduced vascular contraction, elicited by peripheral nerve stimulation, without disturbing endothelial and smooth muscle contractile functions. This reduction may contribute to the prevention of vasospasms.

右冠動脈領域に対するグラフト選択&amp;mdash;大伏在静脈と右胃大網動脈について&amp;mdash;

【目的】当院では右冠動脈領域に対するグラフトについて，右冠動脈の狭窄率が90%未満では大伏在静脈(SVG; saphenous vein graft)を，90%以上では右胃大網動脈(GEA; gastroepiploic artery)を選択してきたが，この治療方針の妥当性を検討した．【方法】2005年3月から2011年7月に施行した単独冠動脈バイパス術症例のうち右冠動脈の血行再建を行った75例を対象とした．グラフトにGEAを使用した群とSVGを使用した群について早期から中期の治療成績を比較検討した．【結果】グラフト早期開存率はSVG群で89%，GEA群で91%であり，48カ月経過時点での心関連イベント回避率はSVG群96.4%，GEA群97.7%でありいずれにおいても有意差を認めなかった．【結論】右冠動脈の狭窄率によってグラフトを選択する当院の治療方針は妥当と考えられた．

右胃大網動脈グラフトによる冠動脈バイパス術後の肝切除術の経験

右胃大網動脈グラフトによる冠動脈バイパス術後の肝切除術の経験

Early angiographic evaluation after off-pump coronary artery bypass grafting

One of the potential drawbacks of off-pump coronary artery bypass is reduced patency compared with conventional coronary artery bypass. This study examined the systematic angiographic evaluation after off-pump coronary artery bypass. Of the 1604 consecutive patients who underwent off-pump coronary artery bypass over 6 years, 1422 (89%) who underwent postoperative angiography were analyzed. Generalized estimating equations logistic analyses were used to investigate potential predictors of graft failure (FitzGibbon B or O). Bilateral internal thoracic arteries were used in 78% of the patients. The mean number of distal anastomoses was 3.7±1.2. The in-hospital mortality rate was 0.4%. Recipient coronary diameter less than 1.5 mm (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.24-2.11) was an independent predictor of graft failure, whereas percent stenosis diameter greater than 75% (OR, 0.71; 95% CI, 0.53-0.93), sequential graft (OR, 0.69; 95% CI, 0.51-0.94), and left main disease (OR, 0.72; 95% CI, 0.53-0.96) were protective factors. In the subanalyses for each conduit, percent stenosis diameter was protective against left internal thoracic artery failure (OR, 0.61), whereas smaller recipient coronary diameter was associated with right gastroepiploic artery and saphenous vein graft failure (OR, 2.37 and 2.36, respectively). Left circumflex artery was associated with gastroepiploic artery graft failure, whereas sequential graft was again protective for the gastroepiploic artery (OR, 4.39 and 0.33, respectively). Smaller coronary diameter would be a predictor of graft failure, whereas percent stenosis diameter greater than 75%, sequential graft, and left main disease would be protective factors for off-pump bypass grafts.

Redo-Coronary Artery Bypass due to Progression of the Celiac Axis Stenosis

We report a redo coronary artery bypass grafting (CABG) in a 55-year-old man. Angina recurred 7 years after the initial surgery. Coronary angiography showed all patent grafts except a faint visualization of the in situ right gastroepiploic artery (RGEA) graft, which was anastomosed to the posterior descending coronary artery, associated with celiac axis stenosis. Redo-CABG was performed at postoperative 10 years because of aggravated angina and decreased perfusion of the inferior wall in the myocardial single photon emission computed tomography. The saphenous vein graft was interposed between the 2 in situ grafts used previously; the right internal thoracic artery and RGEA grafts. Angina was relieved and myocardial perfusion was improved.

ST-segment elevation after abdominal aortic aneurysm repair

We describe a case of post-operative inferior myocardial infarction after abdominal aortic aneurysm repair due to compromise of a gastroepiploic coronary arterial graft.

Percutaneous coronary intervention by retrograde approach for chronic total occlusion of the proximal left anterior descending artery via a gastroepiploic artery graft

Coronary arteries connecting to septal branch are often occluded in post-coronary artery bypass graft cases. A 70-year-old male had undergone CABG; radial artery graft to the LCX, and gastroepiploic artery (GEA) graft to the RCA. Coronary angiography revealed total occlusion in proximal LAD, while both graft vessels had good flow. Retrograde percutaneous coronary intervention (PCI) procedure from the septal channel via GEA graft to the RCA was performed for total occlusion of LAD. Despite the tortuous GEA, deep engagement with a 4-french guiding catheter ensured powerful back-up force. After retrograde wire crossing, two drug-eluting stents were implanted, successfully.

Histological and Morphometric Properties of Skeletonized Gastroepiploic Artery and Risk Factors for Intimal Hyperplasia

The aim of the present study was to examine the histological and morphometric properties of skeletonized gastroepiploic artery (GEA) and the risk factors for intimal hyperplasia. We obtained the redundant distal segments of skeletonized GEAs from 33 patients undergoing coronary bypass surgery and microscopically examined the transverse sections just distal to the most distal anastomoses. Intimal hyperplasia was evaluated on the basis of intima-to-media ratio and percentage of luminal narrowing. Risk factors were examined using multivariate linear regression analysis. The median (range) of lumen diameter at the most distal anastomosis was 3.8 (2.4-6.4) mm; width of intima, 82 (8-418) μm; width of media, 167 (88-351) μm; wall thickness, 250 (118-554) μm; intima-to-media ratio, 0.59 (0.04-3.88), and percentage of luminal narrowing, 12.3 (1.5-28.9). The number of elastic lamina in the media was 4.2 ± 1.8. Atherosclerosis was found in six patients, and medial calcification, in three patients. The median (range) of graft flow and pulsatile index measured by intraoperative transit-time flow meter was 65 (11-141) mL/min and 3.1 (1.4-5.9), respectively. All GEA grafts were patent at the coronary computed tomography angiography before discharge. Estimated glomerular filtration rate was independently associated with intima-to-media ratio (β coefficient = -0.016, P < 0.01) and percentage of luminal narrowing (β coefficient = -0.012, P < 0.01). Skeletonized GEA had sufficient lumen diameter with excellent graft flow and early patency even when used as a sequential graft. Estimated glomerular filtration rate correlates significantly with intimal hyperplasia.

Angiographic predictors of 3-year patency of bypass grafts implanted on the right coronary artery system: A prospective randomized comparison of gastroepiploic artery, saphenous vein, and right internal thoracic artery grafts

Saphenous vein, in situ right gastroepiploic artery, and right internal thoracic artery grafts are routinely used to revascularize the right coronary artery. Little is known about the predictive value of objective preoperative angiographic parameters on midterm graft patency. We prospectively enrolled 210 consecutive patients undergoing coronary revascularization. Revascularization of the right coronary artery was randomly performed with the saphenous vein grafts in 81 patients and the right gastroepiploic artery in 92 patients. During the same study period, 37 patients received right coronary artery revascularization with the right internal thoracic artery used in a Y-composite fashion. All patients underwent a protocol-driven coronary angiogram 3 years after surgery. Preoperative angiographic parameters included minimum lumen diameter percent stenosis measured by quantitative angiography. A graft was considered "not functional" with patency scores of 0 to 2 and "functional" with patency scores of 3 or 4. Angiographic follow-up was 100% complete. A significant difference in the distribution of flow patterns was observed in the 3 groups. In multivariate analysis, the use of a saphenous vein graft was associated with superior graft functionality compared with the other conduits (odds ratio, 6.1; 95% confidence interval, 2.4-15). Graft function was negatively influenced by the minimum lumen diameter (odds ratio, 0.11; confidence interval, 0.05-0.25). In the right gastroepiploic artery and right internal thoracic artery groups, the proportion of functional grafts was higher when the minimum lumen diameter was below a threshold value in the third minimum lumen diameter quartile (0.64-1.30 mm). Preoperative angiography predicts graft patency in the right gastroepiploic artery and right internal thoracic artery, whereas the flow pattern in saphenous vein grafts is significantly less influenced by quantitative angiographic parameters.

Avoiding sternotomy in repeat coronary artery bypass grafting: Feasibility, safety, and mid-term outcome of the transabdominal off-pump technique using the right gastroepiploic artery

Repeat sternotomy is associated with a substantial risk of cardiovascular injury. We evaluated the feasibility and clinical outcome of a transabdominal approach without sternotomy and without cardiopulmonary bypass in repeat coronary artery bypass grafting, using the right gastroepiploic artery to graft vessels of the inferior wall of the heart. From July 1999 to October 2010, 22 patients presenting with only right coronary artery disease underwent reoperation using the transabdominal approach and a skeletonized gastroepiploic artery graft. In all patients but 1, a patent graft to the anterior wall was present. The mean EuroSCORE was 6.4 ± 2.5. All patients had adequate surgical exposure, and no conversion to sternotomy or the use of cardiopulmonary bypass was required. There was no in-hospital mortality. Hospital morbidity included pneumothorax in 1 patient and atrial fibrillation in 2 patients. The median hospital stay was 5 days. Follow-up was complete, and the median follow-up time was 6 years. There were 2 late deaths. Four patients experienced recurrence of angina, of whom three required percutaneous coronary intervention. The estimated freedom from major cardiovascular and cerebrovascular events rate was 70.2% at 6 years. Fourteen patients underwent an exercise stress test at a median interval of 2 years, with all showing no signs of myocardial ischemia. Transabdominal off-pump coronary artery bypass grafting using the right gastroepiploic artery is a safe and effective procedure with low in-hospital mortality and morbidity and favorable mid-term outcome. In redo operations, this technique excludes the risk of cardiovascular injury.

Thoracoabdominal aortic aneurysm repair with patent gastroepiploic artery graft

Thoracoabdominal aortic aneurysm repair with patent gastroepiploic artery graft

Distal gastrectomy for advanced gastric cancer with vascular anomaly after coronary bypass grafting using the right gastroepiploic artery

A 77-year-old woman with a history of coronary artery bypass grafting 5 years earlier presented with anemia and was diagnosed with advanced gastric cancer involving the pylorus. Preoperative angiography revealed that the right gastroepiploic artery (RGEA) graft was patent. Multidetector-row computed tomography showed the running pattern of the RGEA graft and also revealed a vascular anomaly belonging to type V of Adachi's classification. Adachi's type V is a rare vascular anomaly in which the common hepatic artery originates from the superior mesenteric artery. The patient was treated successfully with a distal gastrectomy and removal of the D2 lymph node with preservation of the RGEA graft. Because of the difficulty in confirming the running pattern of the artery during the surgery, it is important to define the arterial running pattern preoperatively by using multidetector-row computed tomography, including 3-dimensional angiographic imaging.

In Off-Pump Surgery, Skeletonized Gastroepiploic Artery is Superior to Saphenous Vein in Patients With Bilateral Internal Thoracic Arterial Grafts

When the bilateral internal thoracic arteries are grafted to the left coronary arteries, it remains controversial whether the better conduit is provided by grafting the saphenous vein graft (SVG) or the gastroepiploic artery (GEA) to the right coronary artery territory. From the beginning of the present study, we consistently used the GEA in a skeletonized fashion using ultrasound scissors. From January 2002 to December 2009, 320 consecutive patients with triple-vessel disease underwent in situ bilateral internal thoracic artery grafting to the left coronary arteries. Among the 320 patients, of whom 229 underwent GEA grafting to the right coronary artery and 91 SVG grafting, 85 propensity score-matched pairs were identified (C statistic, 0.68 [p < 0.001]). The mean follow-up duration was 5.1 ± 2.2 years. Seven-year freedom from death from all causes was 96.0% in the GEA group and 82.2% in the SVG group (p = 0.03); the rate of freedom from cardiac events (cardiac death, myocardial infarction, angina pectoris, repeat intervention, and heart failure) was 89.3% in the GEA group and 77.5% in the SVG group (p = 0.048). Multivariate Cox proportional hazard regression analysis showed that SVG use (without GEA) (p = 0.04; hazard ratio, 0.31; 95% confidence interval, 0.11 to 0.94) and smoking history (p = 0.02; hazard ratio, 0.22; 95% confidence interval, 0.07 to 0.81) were independent predictors of late cardiac event. Skeletonized GEA grafting to the right coronary artery system is better than SVG grafting in patients with left-sided bilateral internal thoracic arterial grafts.