Right Gastroepiploic Artery Graft Research Articles

Surgical management of right hepatectomy after coronary artery bypass grafting using the right gastroepiploic artery: a case report and literature review

BackgroundCoronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) is a well-established, safe procedure. However, problems with RGEA grafts in subsequent abdominal surgeries can lead to fatal complications. This report presents the first case of right hepatectomy for hepatocellular carcinoma after CABG using the RGEA.Case presentationWe describe a case in which a right hepatectomy for an 81-year-old male patient with hepatocellular carcinoma was safely performed after CABG using a RGEA graft. Preoperatively, three-dimensional computed tomography (3D- CT) images were constructed to confirm the run of the RGEA graft. The operation was conducted with the standby of a cardiovascular surgeon if there was a problem with the RGEA graft. The RGEA graft had formed adhesions with the hepatic falciform ligament, necessitating meticulous dissection. After the right hepatectomy, the left hepatic lobe descended into the vacated space, exerting traction on the RGEA. However, this traction was mitigated by suturing the hepatic falciform ligament to the abdominal wall, ensuring stability of the RGEA. There were no intraoperative or postoperative complications.ConclusionIt is crucial to confirm the functionality and anatomy of the RGEA graft preoperatively, handle it gently intraoperatively, and collaborate with cardiovascular surgeons.

A case of laparoscopic hepatic S4 partial resection after coronary artery bypass grafting using the right gastroepiploic artery

AbstractLaparoscopic liver resection has become safer over time, making it a viable option for patients previously considered high‐risk. We discuss a case in which a 73‐year‐old man underwent laparoscopic liver resection after coronary artery bypass grafting using the right gastroepiploic artery (RGEA). The patient was noted to have liver metastases of rectal cancer in the medial segment. Laparoscopic hepatic S4 partial resection was done after preoperative assessment of the RGEA graft pathway by computed tomography. During the operation, the RGEA graft was adherent to the dorsal surface of the liver, but the laparoscopic approach allowed fine dissection. The tumor was then safely removed, and the patient was discharged without complications. Preoperative assessment of the graft pathway is necessary because of the lack of tactile sensation during laparoscopic surgery. However, a magnified view of the laparoscope enabled us to perform fine dissection to avoid injury to the graft vessels.

Early cardiac contractility outcome of reoperative coronary artery bypass grafting using right gastroepiploic artery.

Reoperative coronary artery bypass grafting (redo CABG) still carries higher mortality and increased morbidity compared with primary CABG. In this study, we retrospectively reviewed our operative outcome of redo CABG to evaluate the impact of the left anterolateral thoracotomy approach using the right gastroepiploic artery (RGEA). Between 1994 and 2020, 11 patients (mean age 60.3 ± 13.1 years; nine men, two women) underwent isolated redo CABG using the RGEA via the left anterolateral thoracotomy. The mean duration from the initial CABG was 128.3 ± 88.4 months. Redo CABG was performed because of graft occlusion in six patients (54.5%), graft stenosis in one patient (9.1%), and progressive disease of previously ungrafted vessels in four patients (36.4%). The total number of bypasses using RGEA (including Y-composite vein grafts) was 16 (four left anterior descending branches, two diagonal branches, five circumflex branches, five right coronary arteries). No residual graft injury, major comorbidity, or in-hospital death was observed. Changes in echocardiographic values before and after redo CABG were 210.9 ± 48.2 ml and 175.0 ± 41.4 ml in left ventricular end-diastolic volume, 130.2 ± 49.2 ml and 94.4 ± 33.0 ml in left ventricular end-systolic volume, and 45.6 ± 11.0% and 52.2 ± 10.7% in left ventricular ejection fraction, respectively. These parameters significantly improved after redo CABG. Redo CABG with RGEA grafting via the left anterolateral thoracotomy approach is a safe and effective surgical procedure especially in improving cardiac contractility in patients who required revascularization.

Abdominal surgery for gastric cancer following coronary artery bypass grafting using an in situ right gastroepiploic artery graft.

The right gastroepiploic artery (RGEA) is often used for coronary artery bypass grafting (CABG) in Japan. As gastric cancer has a high prevalence in many Asian countries, we investigated problems with surgery for gastric cancer after CABG using the RGEA. A total of 860 patients underwent CABG using the RGEA between January 1997 and December 2006. Of these, 13 patients underwent surgery for gastric cancer after CABG. In all cases, the RGEA was harvested by the skeletonization technique, and an antegastric route was used for the anastomosis. Dissection for the No. 6 lymph node was not performed in all cases because of the risk of graft injury. Graft injury during gastric surgery occurred in one patient and post-operative ventricular fibrillation (VF) was observed in two patients. One case of hospital death due to VF and two cases of remote death were encountered. In planning a resection for gastric cancer following a CABG with a patent RGEA graft, the potential for graft injury must be anticipated. In advanced stages of gastric cancer when the RGEA needs to be resected to dissect the No.6 lymph node, a pre-operative percutaneous coronary intervention or a reoperative CABG may be indicated.

Fasudil Is an Effective Graft Vasodilator for Gastroepiploic Artery in Coronary Artery Bypass Grafting.

The gastroepiploic artery (GEA) has been used as an alternative arterial in situ graft for coronary artery bypass grafting (CABG). However, because of the large individual differences and the spastic nature of the GEA, caution has to be exercised during harvesting. We evaluated the usefulness of fasudil, a Rho kinase inhibitor, as a vasodilator for right GEA (RGEA) graft after harvesting, compared with the conventional agents papaverine and verapamil-nitroglycerin. Between June 2009 and January 2013, 30 patients with ischemic heart disease who underwent isolated CABG using RGEA graft were randomly assigned to fasudil (n = 10), papaverine (n = 10), or verapamil-nitroglycerin (n = 10) group. Fasudil (2.67 mmol/L), papaverine (1.0 mmol/L) mixed with heparinized blood, or verapamil-nitroglycerin (30 μmol/L each) was injected intraluminally into the RGEA graft after harvesting. Right GEA graft free flow (GFF), hemodynamic changes, and histopathology of RGEA were evaluated. Intraluminal injection of fasudil increased GFF significantly (P < 0.001) and markedly from 41.5 ± 31.5 mL/min at baseline to 149.3 ± 46.7 mL/min after injection. Papaverine increased GFF (P < 0.001) from 40.0 ± 35.8 to 64.9 ± 33.7 mL/min, and verapamil-nitroglycerin also increased GFF (P < 0.001) from 38.8 ± 32.1 to 79.0 ± 35.2 mL/min. The GFF was significantly higher (P = 0.001) in the fasudil group than in the other two groups. Histopathologically, fasudil treatment markedly increased the diameter of RGEA graft, while maintaining integrity of the multiple elastic lamellae. Blood pressure did not change significantly after drug injection in all groups. Fasudil is more potent than papaverine or verapamil-nitroglycerin in increasing GFF of RGEA graft for CABG.

Long great saphenous vein grafting as temporary coronary bypass for extended left hepatectomy: report of a case.

The right gastroepiploic artery (RGEA) has been used in coronary artery bypass grafting (CABG) as an alternative graft. In particular abdominal surgeries, surgery is required to rescue the graft flow into the coronary artery. A 77-year-old male with a history of CABG using RGEA was admitted with a diagnosis of a large hepatocellular carcinoma (HCC) occupying the whole caudate lobe. Preoperative coronary angiography indicated that the graft from the right internal mammary artery to the proximal left circumflex artery was obliterated among three branch bypasses. Following laparotomy, a great saphenous vein was harvested and delivered from the right axial artery to the RGEA graft over the thoracic wall, and the RGEA graft was ligated and divided. Subsequently, extended left hepatectomy was safely performed. Following hepatectomy, the RGEA graft was restored to the former condition, and the temporary graft was removed. After overcoming hyperbilirubinemia, the patient was discharged on postoperative day 28. This experience indicates that temporary bypass using the long great saphenous vein is effective and safe during long and invasive surgeries.

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.

A Potential Risk of Myocardial Ischemia during Thoracoabdominal Aortic Repair after Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery

In-situ right gastroepiploic artery (RGEA) has been used as one of the reliable conduits for coronary artery bypass grafting (CABG). We report a case of thoracoabdominal aortic aneurysm (TAAA) repair in a patient who had previous CABG using the RGEA graft. There is a great potential risk for critical myocardial ischemia when performing open repair for TAAA in those patients.

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.

Pancreatoduodenectomy after Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery: A Case Report

We herein report the case of an advanced ampullary cancer developed 80 months after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) and successfully treated by pancreaticoduodenectomy (PD) with revascularization using the great saphenous vein. A 69-year-old Japanese male was admitted for examination with one-month history of nausea and appetite loss. He underwent three vessel CABG, involving bypassing between the right coronary artery and RGEA about 80 months before. The preoperative diagnosis with CT scan and gastric endoscope was carcinoma of the papilla of Vater. Preoperative abdominal angiography showed the RGEA graft remained well patent. He underwent PD with regional lymph node dissection after revascularization of the RGEA. The postoperative clinical course was uneventful. The histopathological examinations of the resected specimen revealed adenocarcinoma of the ampulla, pT2, pN0, M0 stage IB. The patient is currently alive without any further signs of ischemic heart disease several months after his operation. This case report demonstrates that the radical PD with revascularization using other vein graft can be safely performed after CABG using the RGEA.

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.

Comparison of Right Internal Thoracic Artery and Right Gastroepiploic Artery Y Grafts Anastomosed to the Left Internal Thoracic Artery

Early and 1-year results of arterial Y composite grafts anastomosed to the in situ left internal thoracic artery were studied. Three hundred twelve patients who underwent off-pump coronary artery bypass using arterial Y composite grafts for revascularization of the left coronary artery territory were analyzed. A skeletonized right internal thoracic artery (RITA) or right gastroepiploic artery (RGEA) was anastomosed to the side of the left internal thoracic artery to construct a Y composite graft. Propensity-matched analysis was used to match patients using RITA (RITA group, n = 102) with patients using RGEA (RGEA group, n = 102). Postoperative coronary angiographies were performed early (200 of 204; 1.8 +/- 1.7 days) and 1 year (171 of 204, 11.3 +/- 2.5 months) postoperatively. There were no differences in postoperative mortalities (1 of 102 versus 2 of 102; p = 1.000) and morbidities including atrial fibrillation, mediastinitis, and perioperative myocardial infarction between the RITA and RGEA groups (not significant). Early and 1-year postoperative angiographies showed that there were no significant differences in patency rate between the two groups (early, 99.4% versus 99.3%; p = 1.000; 1-year, 95.4% versus 97.4%; p = 0.251). When the early and 1-year patency rates were compared based on the side-arm graft used, there were no differences in patency rates of RITA versus RGEA grafts between the two groups (early, 99.4% versus 100%; p = 1.000; 1-year, 96.5% versus 97.7%; p = 0.724). Construction of Y composite grafts using the RITA or RGEA showed comparable results including patency rates early and 1 year postoperatively.

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

Anesthetic management of a patient undergoing liver transplantation who had previous coronary artery bypass grafting using an in situ right gastroepiploic artery

We describe successful anesthetic management during living-donor liver transplantation in a 63-year-old man with previous coronary artery bypass grafting (CABG) that employed an in situ right gastroepiploic artery (RGEA). Anesthesia was maintained with 1.5% isoflurane in air/oxygen and fentanyl. A five-lead electrocardiogram, transesophageal echocardiogram, and pacing pulmonary artery catheter evaluated cardiac function. A pacing wire was inserted through the catheter to prepare for intraoperative severe bradyarrhythmia. Olprinone and nicorandil were continuously infused to prevent decrease in coronary arterial blood flow and the collapse of cardiac function. Avoiding disruption of circulation to coronary arteries through injury or spasm of the RGEA graft and preparing for cardiac insufficiency during liver transplantation of a patient with previous CABG using an in situ RGEA is critical.

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.

Two-stage explantation of a cirrhotic liver for liver transplantation in a patient with a coronary bypass using a right gastroepiploic artery

The right gastroepiploic artery (RGEA) has been considered a fair alternative choice for a coronary bypass graft. However, after such nonanatomical anastomosis, it is difficult to plan abdominal surgery without endangering the critical arterial supply. To date, gastrectomies and pancreatoduodenectomies have been reported in patients with RGEA grafts for coronary bypass. We recently performed living donor liver transplantation (LDLT) in a patient who had previously undergone coronary bypass surgery using RGEA 3 years before the LDLT. This is the first case of LDLT after coronary bypass using RGEA. We report our two-stage explantation of the cirrhotic liver without any injury to the RGEA. The patient was a 63-year-old man suffering from end-stage liver failure and persistent cholangitis due to primary sclerosing cholangitis in May 2007. LDLT was indicated, and preoperative angio-computed tomography was performed and revealed that the patent RGEA graft was located on the left lobe of the cirrhotic liver (Fig. 1A). The LDLT was scheduled on May 28, 2007, with the attendance of a cardiac surgeon and full monitoring of cardiac function, including transesophageal ultrasound. Laparotomy showed that the RGEA was on the left lobe of the cirrhotic liver (Fig. 1B). In order to liberate the RGEA, the left lateral segmentectomy was performed first with the Cavitron ultrasonic surgical aspirator system (CUSA; Valley-Lab, Boulder, CO) and saline-linked cautery (Dissecting Sealer DS 3.0, Tissue Link Medical, Inc., Dover, NH) with minimal blood loss (Fig. 1B,C). Subsequently, the remnant right lobe of the liver was explanted without a spastic event of the RGEA being caused; a left lobe graft from a living donor was then implanted. The RGEA was placed on the dorsal side of the graft because this was the natural position of the RGEA (Fig. 1D). No cardiac event occurred throughout the LDLT, with total blood loss of 1900 g during a total operative time of 1015 minutes. The patient’s postoperative course was uneventful, and he was discharged from our hospital on the thirty-first day after the LDLT. As of this writing, he has been doing well for 8 months since the LDLT. Performing LDLT in patients after previous abdominal surgery is a therapeutic challenge. In particular, the gastroepiploic artery used for coronary arterial bypass is a cumbersome entity because damage to the artery can cause significant consequences for the patient, including cardiac infarction. We performed two-stage explantation of the liver because it was impossible to mobilize the cirrhotic liver with the RGEA in place as the RGEA was present on the left lobe of the liver. After we recognized the situation through a preoperative three-dimensional recon-

How do we manage the gastrectomy for gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery? Report of two cases and a review of the literature

BackgroundRecently, the right gastroepiploic artery (RGEA) has been used in coronary artery bypass grafting (CABG) as an alternative arterial graft. Unfortunately, an increased incidence of gastric cancers has been reported after CABG using the RGEA. Handling of the RGEA during gastrectomy in these patients may cause lethal complications, which sometimes reduces the feasibility of curative dissection of lymph nodes at the base of the graft.Case presentationsWe describe two cases of gastric cancer undergoing gastrectomy after CABG with the use of RGEA. To avoid the potentially fatal coronary event during gastrectomy, safe handling of the conduit including preparations for injuries and prevention of vessel spasm was performed in both cases, accompanied by an adequate monitoring of the systemic circulation. Intraoperative frozen section examination showed no lymph node metastasis around the graft in any of the cases; therefore, complete lymph node dissection at the base of the graft was not undertaken. No complications occurred during the operation. In addition to these two cases, twenty-four cases reported in the literatures were reviewed (a total of 26 cases). Ten early and 16 advanced gastric cancers were included. Among the 16 advanced gastric cancer cases, an alternative graft was employed in 8 due to the resection of an original graft to complete lymph node dissection. Mere handling of a graft often caused lethal complications suggesting that the operation should be completed by isolation of the graft. A pedicled graft harvesting via the ante-gastric route was popular. However, a skeletonized harvesting with resection of the pyloric branches of the RGEA would be better because this would interrupt the original lymph flow, which could eliminate the need for lymph node dissection and graft isolation. Among the 10 cases having early gastric cancers, 6 were found within 1.5 years after CABG. Early detection in these 6 cases was possible due to the use of gastric fiberscopic examination before and after CABG, which gave them opportunities to receive a less extensive operation such as endoscopic mucosal resection.ConclusionAdequate intraoperative care as well as an optimal lymph node dissection considering the graft harvesting method at the first CABG leads to successful gastrectomy after CABG using the RGEA graft. Therefore, this operation should be carried out with careful management by both gastrointestinal and cardiovascular surgeons.

Randomized comparative study of radial artery and right gastroepiploic artery in composite arterial graft for CABG

Arterial grafts have been used to achieve better long-term results and improve graft patency in coronary artery bypass grafting. Composite graft was proposed to overcome inconveniences of proximal anastomoses to the aorta and increase the use and surgical options of arterial grafts. However, lack of prospective randomized studies with this kind of grafts is evident. We compare the results of composite Y-grafts of the radial artery (RA) and the right gastroepiploic artery (RGEA) proximally anastomosed to the left internal thoracic artery (LITA) for CABG, evaluated through angiography, in a prospective randomized study. Between August 1998 and November 1999, 60 patients were randomly divided into two groups: group I (GI) received RGEA graft and group II (GII), RA graft. LITA was used to graft the left anterior descending artery and RGEA or RA was placed to obtuse marginal or first diagonal branch. The right coronary artery branches was grafted with saphenous vein graft (SVG) when necessary. All coronary arteries receiving arterial grafts had > or =75% proximal stenosis and diameter > or =1.5 mm. GI and GII preoperative data were similar, 63 distal anastomoses were performed with the LITA, 32 with the RA and 32 with the RGEA. There were two perioperative deaths (3.3%), one in each group, none related to cardiac causes. Four (6.6%) q-wave myocardial infarctions were found and two (3.3%) patients showed low cardiac output syndrome. Angiography was performed in all surviving patients from the 8th to 15th postoperative day and showed a patency rate of 96.5% (56/58) for LITA, 89.6% (26/29) for RA and 68.9% (20/29) for RGEA, with a statistically significant difference between RGEA and RA (P=0.025). Radial artery had better early results than right gastroepiploic artery. Use of the LITA as inflow graft seems not to affect its good patency. Use of the RGEA as composite graft should not be encouraged. Long-term follow-up with objective investigation and randomized trials is required to confirm better results of composite conduits.

Comparison of the Postoperative Blood Flow Waveforms of the Bypassing Grafts in Patients Following Minimally Invasive Direct Coronary Artery Bypass

To use Doppler ultrasound velocimetry to detect and compare the postoperative flow characteristics of the bypassing grafts in patients following minimally invasive direct coronary artery bypass surgery (MIDCAB). From January 1997 to June 1999, 34 patients underwent MIDCAB with the left internal thoracic artery (LITA) to the left anterior descending coronary artery (LAD) [n = 23], with the right gastroepiploic artery (RGEA) to the right posterior descending artery (RPD) [n = 3], or with the LITA with a saphenous vein graft extension to the LAD (n = 6), the diagonal coronary artery (n = 1), or the right acute coronary artery (n = 1). There were two patients with LITA to the LAD and RGEA to the RPD. Patients underwent MIDCAB due to coronary artery stenosis (100% occlusion, n = 10; 90 to 99% stenosis, n = 18; < 90% stenosis, n = 5) or unsuccessful percutaneous transcoronary angioplasty with dissection (n = 1). All patients underwent flow velocity measurement by Doppler ultrasound velocimetry in the immediate postoperative period, and at 6-month and 12-month intervals; graft flows were quantified based on Doppler velocimetric data. The results showed that in a patient with a totally occluded LAD or RPD, typical biphasic velocity waveforms were consistently observed. However, a delayed diastolic wave was noted in RGEA grafts. In patients with less-occluded stenotic lesions or with strong back flows, the flow velocity patterns showed biphasic waveforms but systolic reversal was observed in the area closest to the anastomotic site. The presence of an LAD or RPD stenosis proximal to the anastomotic site significantly affects the LITA or RGEA graft flow volume. The biphasic flow pattern proves that an LITA or RGEA graft transports the blood primarily to coronary arteries during the diastolic phase.

Intraoperative flow measurements in gastroepiploic grafts using pulsed Doppler.

The patency of a pedicled right gastroepiploic artery (RGEA) graft can be compromised by intraoperative twists, kinks or spasms. Therefore, a systematic flow assessment was made in RGEA grafts and was compared with similar measurements made in other types of bypass conduits. Intraoperative pulsed Doppler flowmeter measurements obtained in a series of 556 consecutive patients undergoing at least one coronary bypass grafting onto the right coronary system were studied. Eighty-five RGEA grafts were compared with 1427 bypass grafts implanted in the same group of patients and consisted of the following conduits: 442 left internal mammary (LIMA), 149 right internal mammary (RIMA), 831 greater saphenous vein (GSV) and five inferior epigastric (EPIG) grafts. Sequential grafts were excluded from the analysis. Flow measurements and Doppler waveforms were abnormal and required graft repositioning, and the addition of a distal graft or intragraft papaverine injection (only in GSVs) in 29 cases (2.0% of all grafts). These graft corrections were necessary in 5.9% RGEAs, 3.4% LIMAs, 2.0% RIMAs, and 0.7% GSVs (P < 0.001). The relative risk for graft correction was eight times higher for RGEAs than for GSVs (P = 0.002). Flow increased from 8 +/- 2 to 54 +/- 5 ml/min (P < 0.0001). Flow data were significantly influenced by the type of run-off bed (P < 0.001), the measurements obtained in grafts implanted onto the right coronary artery and the left anterior descending artery being superior. Flows in RGEAs, however, were comparable with values obtained in other grafts implanted onto the same recipient coronary artery. A significantly higher incidence of graft malpositioning caused inadequate flows in RGEAs. However, normal flow values could be restored simply by assigning a better graft orientation under pulsed Doppler flowmeter control. Overall flow capacity of the RGEA did not differ from values obtained in other arterial and venous grafts implanted onto the same recipient arteries.