Procedure

The right gastroepiploic artery graft

Hayama Heart Center, 1898 Shimoyamaguchi, Hayama, Kanagawa 240 0116, Japan

^* Corresponding author: ^* Tel.: +81 468 75 1717; fax: +81 468 75 3636. E-mail: isomura{at}hayamaheart.gr.jp

	Summary

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This is the presentation of coronary artery bypass grafting with gastroepiploic artery (GEA) in both skeletonized GEA harvesting technique and anastomosis: After median sternotomy and harvesting internal thoracic artery, the median incision is extended less than one inch. Following laparotomy, dissection of GEA is started from two third distal of the great curvature of the stomach and ended above the pylorus. The GEA is passed into pericardial cavity through a small tunnel in the diaphragm. The most common site of the anastomosis is distal right coronary artery (postero-descending or atrioventricular branch or both). The suture starts from the left side of the "heal" of the GEA and proceeds in a counter-clockwise fashion for three stitches until pulling down the GEA to the coronary artery. After the completion of the anastomosis, the clamp of the GEA is released to check the anastomotic hemostasis. The technique for harvesting skeletonized GEA is shown and an overview of the literature of the CABG using GEA is presented.

Key Words: Gastroepiploic artery • Coronary artery bypass grafting • Pedicle • Skeletonization • Aorta no-touch technique

	Introduction

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History
The right gastroepiploic artery (GEA) was used for indirect myocardial revascularization by Bailey [1], Vineberg [2], and their colleagues in the 1960s. Sterling Edwards utilized the GEA for coronary artery bypass grafting in the early 1970s [3], though there was no exact documentation. One and a half decade later, the GEA was revived as a new arterial conduit following general recognition of the superiority of the internal thoracic artery (ITA) over the saphenous vein (SV) graft in coronary artery bypass grafting [4,5].

	Surgical technique

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The GEA is detached as a pedicle or in a skeletonized fashion along the greater curvature of the stomach. Usually the GEA is taken down to two-thirds of the greater curvature. Detachment of the GEA at the proximal site should be limited to the lower margin of the pylorus. Endoscopic Doppler flow study has shown no ischemia in the greater curvature after detachment of the GEA from the stomach [6]. Prior to the anastomosis, 3–4 ml of diluted papaverine hydrochloride (40 mg in 10 ml physiological saline) is injected into the GEA lumen from the distal cut end to relieve spasm. Because the GEA is a muscular artery, strong spasms frequently occur by manipulation for take down. Intraluminal papaverine is an essential procedure to obtain good caliber and flow for successful anastomosis.

The GEA pedicle is then introduced into the pericardial space through the hole in the diaphragm made by electrocautery, passing the anterior surface of the stomach and the liver (Schematic 1). Anastomosis between the GEA and the coronary artery is made by an 8-0 suture similar to that of the ITA. The GEA is occasionally used as a free graft. The harvesting technique is the same as that of an in situ GEA graft described above.

View larger version (111K): [in this window] [in a new window]   Schematic 1 The most common site of the anastomosis is distal RCA (posterodescending artery, PD or atrioventricular branch, AV). The pedicled or skeletonized GEA is passed into pericardial cavity anterior to the stomach via a small hole in the diaphragm (Anterior root).

	Surgical procedure

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The ordinal median incision is extended to approximately one inch and the peritoneum is opened (Video 1). The GEA is prone to spasm, therefore, diluted papaverine is used during harvesting the GEA (Videos 2, 3). The side branches of the GEA and GE-vein are more than those of the ITA and those branches are carefully trimmed and the GE-vein is separated from the GEA as a skeletonized harvesting (Videos 4, 5, 6, 7).

Click on image to view video Video 1 Laparotomy. After the harvest of the left internal thoracic artery (ITA), the midline incision of the median sternotomy is extended less than one inch. The peritoneum is then opened. The gastroepiploic artery (GEA) is usually buried in the thick fatty tissue.

Click on image to view video Video 2 Dissection of the GEA. The GEA originates from the gastroduodenal branch of the celiac artery. Dissection of the GEA is started from the 2/3 distal end of the great curvature of the stomach. Diluted papaverine (1:20 dilution) is injected into the fatty tissue and the fatty tissue above the GEA is dissected.

Click on image to view video Video 3 The GEA is parallel to the gastroepiploic vein, which is dark color. At this point when the size of the GEA is larger than 1.0–1.5 mm in diameter, it is useful for grafting. The GEA is prone to spasm, it is important to spray or inject the diluted papaverine solution during the harvest of the GEA.

Click on image to view video Video 4 Side branches and skeletonization of the GEA. There are many branches from both the GEA and the GE-vein, and they are trimmed by clipping both proximal and distal portions.

Click on image to view video Video 5 After harvesting the GEA for a length of one inch, the GEA is separated from the GE-vein and the vessel loop is passed around the GEA.

Click on image to view video Video 6 By pulling the vessel loop, the GEA is dissected toward proximal portion. The GEA is dissected until the location above the pylorus. In this case, another surgeon simultaneously harvests the right ITA.

Click on image to view video Video 7 Treatment of the skeletonized GEA. After systemic injection of heparin (1 mg/kg or ACT>200 sec), the distal end of the GEA is clipped and cut.

Click on image to view video Video 8 Through the distal end of the GEA, the diluted papaverine solution is injected intraluminally by using a 3F neonate feeding tube and the end is clipped.

Click on image to view video Video 9 Length of the GEA. The length of the GEA is usually long enough to reach the distal right coronary artery. The skeletonized GEA is getting larger than the pediced one. In most instances, the diameter of the GEA is larger than biliateral ITA grafts.

Click on image to view video Video 10 The long skeletonized GEA. The GEA sometimes reaches to the ascending aorta.

Click on image to view video Video 11 Anterior root of the GEA. After cardiopulmonary bypass and cardioplegic heart arrest, a small hole is made in the diaphragm and the GEA is passed into pericardial cavity anterior to the stomach.

Click on image to view video Video 12 The distal end is fixed with micro-haemostatic forceps and the distal end is trimmed and cutback longitudinally.

Click on image to view video Video 13 Anastomosis of the GEA. The most common site of the anastomosis is distal RCA (posterodescending artery=PD or atrioventricular branch=AV). The stitch using 8-0 Prolene starts from the left side of the "heel" of the GEA and proceeds in a counterclockwise fashion for three stitches until pulling down the GEA to the coronary artery.

Click on image to view video Video 14 After pulling down the GEA, the sequences of the anastomosis are performed in a clockwise fashion toward the side and complete the anastomosis.

Click on image to view video Video 15 Before tie the suture, clamp of the GEA is released to evacuate the air in the artery.

Click on image to view video Video 16 In this case, sequential anastomosis of the GEA to both PD and AV is completed.

Click on image to view video Video 17 Hemostasis. After the completion of the anastomosis, the clamp of the GEA is released to check the anastomotic leak. If the leak is detected, a U-stitch of 8-0 Prolene is applied to repair it. It is important to check the anastomotic leak by releasing the GEA clamp before declamping ascending aorta and heart beating.

Click on image to view video Video 18 Angiogram. Postoperative angiogram is performed via left brachial artery into the gastroduodenal artery and in this case, large GEA provides good flow to both PD and AV branches.

Click on image to view video Video 19 Off-pump bypass and aorta no-touch technique. The proximal portion of the long skeletonized GEA can be anastomosed to PD with off-pump technique.

Click on image to view video Video 20 The distal portion of the above mentioned GEA (Video 19) can be used as composite Y-graft LITA for anastomosis to circumflex in off-pump bypass surgery.

	Technical innovations

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In off-pump bypass surgery (Videos 19, 20), aortic no-touch technique can be achieved by using bilateral mammary arteries and the GEA. This aorta no-touch technique can reduce the risk of embolic event due to aortic cross-clamp or proximal anastomosis of ascending aorta.

	Results

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• Operative mortality has been reported to be 1–3% including 1.5% of 1118 in our experience [7,8,9,10,11,12].
  
• Late outcome is good with concomitantly used internal thoracic artery graft. Five- and 10-year survival has been reported to be 92–95% and 87%, respectively [9,10,12].
  
• Incidence of postoperative abdominal complication was low [6,11].
  
• Postoperative exercise performance after CABG with GEA was excellent [13].
  
• Angiographic patency has been reported to be 94–98% at early postoperative period, and 80–85% at 5 years [8,10,11,14,15].
  
• Cumulative patency rate of in situ GEA graft was 91.4%, 80.5% and 62.5% at 1.5 and 10 years in our experience [8]. The most common cause of late occlusion of the GEA graft was primary anastomotic stenosis and anastomosis to a coronary artery with a low-grade stenosis (competitive flow). In other words a good anastomosis to the critically stenotic coronary artery improves GEA patency.
  
• Skeletonized GEA graft shows favorable result [15,16].
  

	References

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