Ann Thorac Surg 1997;63:1470-1472
© 1997 The Society of Thoracic Surgeons
Case Report
Ischemic Gastric Ulcer After Coronary Bypass Using the Right Gastroepiploic Artery
Pascal Schroeyers, MD,
Gebrine El Khoury, MD,
Pierre Goffette, MD,
Yves d'Udekem, MD,
Robert A. Dion, MD
Departments of Cardiovascular and Thoracic Surgery and Neuroradiology, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, Brussels, Belgium
Accepted for publication December 10, 1996.
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Abstract
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The gastroepiploic artery has been widely used for complete arterial myocardial revascularization of young patients. Gastric complications related to the harvesting of this artery are exceptional. We describe here a case of ischemic gastric ulcer due to the use of a gastroepiploic artery in a patient with severe celiac trunk disease. The patient was cured by angioplasty completed by a stenting procedure.
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Introduction
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The right gastroepiploic artery (GEA) appears to be a promising arterial graft, considering its anatomic and pharmacologic properties and its mid-term patency rate. Combined with the use of both intrathoracic arteries, the GEA allows complete myocardial revascularization in young patients.
Abdominal complications after GEA harvesting are few. Postoperative bleeding and incisional hemorrhage are the most frequently observed [1, 2].
Although the gastric mucosal blood flow is supposedly not impaired after harvesting of the GEA [3], we report here a case of ischemic gastric ulcer after myocardial revascularization using the GEA.
A 64-year-old man presented with exertional angina. He had a past history of unstable angina related to a severe right coronary artery stenosis treated by multiple coronary angioplasty and stenting. He was known to have hypercholesterolemia and severe hypertension. Angiography showed good left ventricular function and three-vessel disease with an 80% stenosis of the left anterior descending artery, an 80% stenosis of the first and second marginal branches of the circumflex artery, and a 90% stenosis of a diffusely diseased right coronary artery.
Since 1989, it has been our policy in our institution to perform multiple arterial revascularization in selected cases, with the use of both internal thoracic arteries and the GEA. We have used a GEA in more than 400 patients up to April 1996.
The following bypass grafts were performed: the left internal mammary artery was anastomosed to the distal part of the second marginal branch, the right internal mammary artery to the left anterior descending artery, and the GEA to the posterior descending artery. The first marginal artery was grafted with a saphenous vein. The GEA was routed to the pericardial cavity, anterior to the pylorus and the left lobe of the liver, through an incision in the diaphragm. The procedure went uneventfully. The aortic cross-clamp time was 84 minutes.
Six hours after his arrival in the intensive care unit, a first attempt at extubation failed. He became agitated and complained by signs of severe epigastric pain. Although his hemodynamics remained remarkably stable and his electrocardiogram was unchanged, blood gas analysis showed severe acidosis. On the 12th postoperative hour, gastroscopy demonstrated a huge ischemic ulcer of the gastric wall. Selective angiography of the celiac trunk revealed a subocclusive ostial stenosis; the left gastric artery was poorly perfused and the GEA was not visualized (Fig 1
). Selective injection of the superior mesenteric artery showed, via the opacification of the pancreaticoduodenal collaterals, that the GEA was still patent. After celiac angioplasty and stenting by a Palmaz type P 154 prosthesis, the patency of the celiac trunk and its branches was restored and the flow in the left gastric artery was increased (Figs 2, 3).
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Fig 3. . Aortography after celiac angioplasty. (Single arrow = gastroepiploic artery; double arrow = posterior interventricular artery.)
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A follow-up gastroscopy at the 15th postoperative day showed a good healing of the gastric ulcer. After uneventful recovery of 3 weeks, the patient was discharged.
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Comment
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Although the GEA has been increasingly used for coronary revascularization, description of intraabdominal complications are exceptional. Grandjean and associates [1] reported 1 case of gastrointestinal bleeding out of 300 consecutive patients treated with a GEA graft. Jegaden and colleagues [2], in 400 patients, encountered only one intestinal occlusion. Both cases were treated conservatively. Gastric perforation probably related to excessive coagulation of the side branches of the GEA was the first serious gastric complication described [4]. In normal individuals, laser Doppler studies have demonstrated no reduction of the gastric mucosal blood flow after GEA harvesting. In our case, because of the proximal stenosis of the celiac trunk, the blood supply of the whole stomach was dependent on the superior mesenteric artery via the pancreaticoduodenal collaterals and the GEA. The harvesting of the GEA interrupted this collateralization, and the stomach, left underperfused, became ischemic. The reversal of the ischemic lesions could only be achieved by the revascularization of the left gastric artery after stenting of the celiac trunk.
The atherosclerotic changes in the GEA seems to correlate with the severity of coexistent peripheral vascular disease, hypercholesterolemia, and age. Because of potential atherosclerosis of the celiac trunk and its branches, the use of the GEA should be approached with caution in elderly patients with a diseased aorta. Intraoperative assessment of the GEA by palpation and direct vision may not be sufficient, and preoperative selective angiography of the GEA could be beneficial in these patients. Furthermore, we stress the importance of early agressive postoperative diagnosis of intraabdominal complications after the use of the GEA. This attitude led us to a conservative management of this serious abdominal complication after harvesting of the GEA.
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Footnotes
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Address reprint requests to Dr Dion, Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B - 1200 Brussels, Belgium.
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References
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- Grandjean JG, Boonstra PW, den Heyer P, Ebels T. 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]
- Jegaden O, Eker A, Montagna P, et al. Technical aspects and late functional results of gastroepiploic bypass grafting (400 cases). Eur J Cardiothorac Surg 1995;9:575–81.[Abstract/Free Full Text]
- Suma H, Wanibushi Y, Furuta S, Takeuchi A. Does use of gastroepiploic artery graft increase surgical risk? J Thorac Cardiovasc Surg 1991;101:121–5.[Abstract]
- Witkop J, Dillemans BRS, Grandjean JG, Bams JL, Ebels T. Gastric perforation after aortocoronary bypass grafting with right gastroepiploic artery. Ann Thorac Surg 1994;58:1170–1.[Abstract/Free Full Text]
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Abstract
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