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Ann Thorac Surg 1996;61:1853-1855
© 1996 The Society of Thoracic Surgeons

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How To Do It

Coronary Reoperation via Small Laparotomy Using Right Gastroepiploic Artery Without CPB

Thoraxcenter, University Hospital of Groningen, Groningen, the Netherlands

Accepted for publication February 13, 1996.

	Abstract

Top Footnotes Abstract Introduction Technique Results Comment References

 
The elective use of the right gastroepiploic artery as an in situ graft has been well established in coronary surgery. We propose a surgical technique for patients undergoing coronary reoperations with a patent mammary graft to the left anterior descending artery. The gastroepiploic artery is used through a small laparotomy when only the right coronary artery or the posterior descending artery needs revascularization. The described technique allows avoidance of both resternotomy and cardiopulmonary bypass.

	Introduction

Top Footnotes Abstract Introduction Technique Results Comment References

 
The use of the right gastroepiploic artery (GEA) as an elective pedicle graft for coronary operation, along with the internal mammary arteries, has been recently established in large series of patients [1–3]. However, the routine use of the internal mammary artery at the first coronary operation may create a troublesome situation during reoperations, in particular if a patent arterial graft lies in the midline, behind the sternum [4]. Alternative techniques, eg, the small anterior left thoracotomy, have been used to avoid both resternotomy and cardiopulmonary bypass in these patients [5]. We propose a surgical technique for patients undergoing coronary reoperations with patent mammary graft to the left anterior descending artery and in need of revascularization of the right coronary artery or posterior descending artery.

	Technique

Top Footnotes Abstract Introduction Technique Results Comment References

 
The patient is prepared and positioned as for the standard midline sternotomy. The perfusionist is on stand-by and the heart-lung machine is not primed. An incision of 10 to 15 cm is made on the inferior aspect of the previous sternotomy (approximately two-thirds of the length of the incision caudally and one-third cephalad to the xyphoid). The xyphoid is removed, freeing it from the adhesions by means of electrocautery, and a conventional sternal retractor is used to provide adequate exposure. Then the peritoneum is opened in the midline and the GEA is harvested by dividing the branches with electrocoagulation between two surgical clips on both sides (stomach and omentum) [2]. The fat pedicle is then infiltrated with a 0.1 mg/mL papaverine solution. Then the undersurface of the last 5 cm of the sternum is freed from the adhesions, a T-shaped incision is made in the lower part of the sternum with the oscillating saw (Fig 1), and the conventional spreader is positioned and gently opened, spreading only the lower part of the sternum. The diaphragmatic surface of the heart is dissected free from the diaphragm, thus exposing the posterior descending artery or the right coronary artery.

View larger version (59K): [in this window] [in a new window]   Fig 1. . Surgical access: The skin incision of 10 to 15 cm is made onto the lower part of the previous sternotomy (approximately two-thirds of the length of the incision caudad and one-third cephalad to the xyphoid). If present, the lowest sternal wire is removed. The thick lines represent the T-shaped incision made with the oscillating saw in the lower part of the sternum. Then a conventional sternum spreader can be positioned and gently opened, spreading the lower part of the sternum.

Two stay sutures are applied to the diaphragmatic pericardium and pulled upward. Two additional stay sutures are used to pull caudally the free anterior edge of the diaphragm, thus providing good exposure of the inferior aspect of the heart. Like in all our patients where we use the GEA, the GEA is routed anterior to the pylorus and left liver lobe and enters into the pericardium through a hole in the diaphragm anterior of the inferior caval vein. The target coronary vessel is then surrounded with two 5-0 polypropylene looping sutures (Prolene; Ethicon, Inc, Somerville, NJ), proximally and distally to the site of the arteriotomy [5]. The GEA-to-coronary anastomosis is then performed using a running 7-0 Prolene suture on the beating heart. The pedicle is fixed next to the anastomosis. Heparin is reversed with the equivalent dose of protamine at the end of the operation. The peritoneum is then closed with an absorbable running suture, and soft tissues are closed as routinely. For closing the T-shaped incision of the sternum one sternal wire is used to approximate the inferior part of the sternum.

	Results

Top Footnotes Abstract Introduction Technique Results Comment References

 
From June 1994 to November 1995, 5 patients with previous coronary operations (Table 1) and recurrence of angina underwent coronary reoperation according to the above-described technique. Preoperatively they all were in Canadian Cardiovascular Society class III, regardless of full pharmacologic treatment. Cardiac catheterization (Fig 2) showed in 4 cases the occlusion of previous venous grafts to the right coronary artery and in 1 case progression of atherosclerotic disease affecting a previously undiseased right coronary artery. In all cases the left internal mammary graft to the left anterior descending artery was found to be patent.

View larger version (151K): [in this window] [in a new window]   Fig 2. . Preoperative angiography: injection of the right coronary artery in left anterior oblique projection, showing diffuse disease of the medium tract of the artery.

Postoperative course was uneventful in all cases. One-month postoperative treadmill stress test and the following treadmill tests were negative for recurrence of angina. In patients 1 and 2, 1-year postoperative angiographic study showed the patency of the GEA graft to the posterior descending artery (Fig 3). Patients 3 and 4 refused the study. Patient 5 was not selected for angiographic study due to the presence of an aorto-bifemoral prosthesis, previously implanted for the surgical treatment of Leriche syndrome. All patients underwent postoperative color-Doppler echographic imaging [6] of the GEA, which showed a pattern of diastolic flow indicating the patency of the pedicled graft.

View larger version (83K): [in this window] [in a new window]   Fig 3. . Postoperative angiography. (A) Selective injection of the celiac trunk, with the visualization of the proximal part of the pedicled gastroepiploic artery graft. (B) Gastroepiploic artery-to-right coronary artery anastomosis in left anterior oblique projection.

	Comment

Top Footnotes Abstract Introduction Technique Results Comment References

The surgical technique that we describe is effective to avoid all the above-mentioned risks and can be used safely in patients undergoing coronary reoperations with patent mammary graft to the LAD and with the need for revascularization of the right coronary artery or posterior descending artery with a certain diameter of more than 1 to 1.5 mm. Some experience in operating on the beating heart is fundamental.

	Footnotes

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Address reprint requests to Dr Grandjean, Department of Cardiothoracic Surgery, University Hospital of Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands.

	References

Top Footnotes Abstract Introduction Technique Results Comment References

 

1. Suma H, Wanibuchi Y, Terada Y, et al. The right gastroepiploic artery graft: clinical and angiographic midterm results in 200 patients. J Thorac Cardiovasc Surg 1993;105:615–23.[Abstract]
2. Grandjean JG, Boonstra PW, Den Heyer P, et al. Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients. J Thorac Cardiovasc Surg 1994;107:1309–16.[Abstract/Free Full Text]
3. Jegaden O, Eker A, Montagna P, et al. Risk and results of bypass grafting using bilateral internal mammary grafting and right gastroepiploic arteries. Ann Thorac Surg 1995;59:955–60.[Abstract/Free Full Text]
4. Joyce FS, McCarthy PM, Taylor PC, et al. Cardiac reoperations in patients with bilateral internal thoracic artery grafts. Ann Thorac Surg 1994;58:80–5.[Abstract/Free Full Text]
5. Benetti FJ, Ballester C, Sani G, Boonstra PW, Grandjean JG. Video assisted coronary bypass surgery. J Cardiac Surg 1995;10:620–5.[Medline]
6. Nishida H, Endo M, Koyanagi H, et al. Coronary artery bypass grafting with the right gastroepiploic artery and evaluation of flow with transcutaneous Doppler echocardiography. J Thorac Cardiovasc Surg 1994;108:532–9.[Abstract/Free Full Text]
7. Grover FL, Johnson RR, Marshall G, et al. Factors predictive of operative mortality among coronary artery bypass subsets. Ann Thorac Surg 1993;56:1296–307.[Medline]
8. Moshkovitz Y, Lusky A, Mohr R. Coronary artery bypass without cardiopulmonary bypass: analysis of short-term and mid-term outcome in 220 patients. J Thorac Cardiovasc Surg 1995;110:979–87.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Massimo A. Mariani Tjark Ebels Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grandjean, J. G. Articles by Ebels, T. Search for Related Content PubMed PubMed Citation Articles by Grandjean, J. G. Articles by Ebels, T.