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Ann Thorac Surg 1998;65:444-448
© 1998 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Minimally Invasive Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery

Sari Voutilainen, MD, Kalervo Verkkala, MD, PhD, Antero Järvinen, MD, PhD, Markku Kaarne, MD, Pekka Keto, MD, PhD, Petri Voutilainen, MD, Severi Mattila, MD, PhD

Department of Thoracic and Cardiovascular Surgery and Diagnostic Radiology, Helsinki University Central Hospital, Helsinki, Finland

Accepted for publication August 8, 1997.

Dr Voutilainen, Department of Thoracic and Cardiovascular Surgery, Helsinki University Central Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background. Anastomosis of the left internal thoracic artery to the left anterior descending artery without sternotomy and without cardiopulmonary bypass is a standard approach in minimally invasive coronary artery bypass grafting. To expand the indications for minimally invasive coronary artery bypass grafting from one-vessel disease to two-vessel disease, we began to perform anastomosis of the right gastroepiploic artery (RGEA) to the right coronary artery (RCA).

Methods. From February to November 1996, an RGEA graft was used in 25 of the 100 patients who underwent minimally invasive coronary artery bypass grafting at our clinic. Eleven of the patients had only RCA disease and 14 had both RCA and left anterior descending artery disease. One of the operations was a redo coronary artery bypass grafting. The RGEA was anastomosed to the RCA through a laparotomy incision and the left internal thoracic artery was anastomosed to the left anterior descending artery through a left anterior thoracotomy. In 5 patients, the RGEA was lengthened by venous grafting.

Results. All patients underwent angiography after operation; 82.6% of the RGEA grafts and all the left internal thoracic artery grafts were functioning well. In three of the four nonvisualized RGEA grafts, the percentage of proximal stenosis of the RCA seen on postoperative angiography was not critical (40%, 50%, and 50%, respectively), allowing significant competitive flow through the native bypassed RCA. The patency of all the RGEA grafts without competitive flow was 95%, with a 95% confidence interval of 75.1% to 99.9%.

Conclusions. The indications for minimally invasive coronary artery bypass grafting could be extended to primary operations in patients with left anterior descending artery and RCA lesions by using both the left internal thoracic artery and the RGEA.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Internal thoracic artery grafts have been used successfully for more than 20 years and right gastroepiploic artery (RGEA) grafts have been used for about 10 years in patients undergoing coronary artery bypass grafting (CABG), with excellent intermediate- to long-term results compared with venous grafts [1] [2] [3] [4] [5] [6] [7] [8]. Percutaneous transluminal coronary angioplasty (PTCA) as an alternative to CABG in selected patients has been used since 1985 [9]. Coronary artery bypass grafting performed without cardiopulmonary bypass (CPB) or full sternotomy recently has been introduced, especially for patients who have one vessel disease or are undergoing redo CABG [10] [11] [12] [13] [14] [15] [16]. The left internal thoracic artery (LITA) has been used to bypass the left anterior descending artery (LAD) through a left anterior small thoracotomy [10] [11] [15]. In patients with right coronary artery (RCA) disease, mainly the right internal thoracic artery has been used [16] [17]. However, in one series, five reoperations were performed with anastomosis of the RGEA to the RCA [12]. In our patients, who underwent primary coronary operations, the RCA disease often was too peripheral for a right internal thoracic artery graft. Therefore, we decided to use the RGEA either alone or lengthened with a venous graft to bypass the RCA disease.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Patients
Between February and November 1996, 935 CABG operations were performed at our clinic. One hundred patients underwent minimally invasive direct coronary artery bypass grafting (MIDCABG), 25 with an RGEA graft. The mean age of the patients who received an RGEA graft was 57.0 ± 10.9 years (range, 38.3 to 81.7 years). The study was approved by the ethical committee of the Department of Thoracic and Cardiovascular Surgery at Helsinki University Central Hospital, and all patients gave their informed consent. The inclusion criteria for MIDCABG with RGEA grafting were RCA disease without three vessel or left main disease and anatomic unsuitability for PTCA or restenosis after PTCA. Eleven patients had a history of one or two acute myocardial infarctions. Sixteen of the patients were men and one of the operations was a redo CABG. There were 14 patients with two vessel disease and 11 with RCA disease alone. Before operation, the mean left ventricular ejection fraction was 0.58 ± 0.17 (Fig 1a). A previous PTCA had been performed in 8 patients. Functionally, 7 of the patients were in New York Heart Association (NYHA) class IV before operation, 9 were in class III, and 9 were in class II.



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  		(a) Ejection fraction (EF), (b) creatine kinase-myocardial band (CK-MB) level, and (c) hospital stay.

 
All the 14 LITA grafts were anastomosed to the LAD. In 22 of the 25 patients, the RGEA graft was anastomosed to the distal part of the RCA. In the other 3 patients, it was anastomosed to the right posterior interventricular artery. In 5 patients (20%), the RGEA was not long enough and it had to be lengthened, using a saphenous vein graft, to reach to the RCA. These patients were somewhat obese, with body mass indexes (weight x 100/height2) of 0.25, 0.26, 0.27, 0.29, and 0.31, respectively. In the patient who had a body mass index of 0.27, the LITA also had to be lengthened using the inferior epigastric artery. At postoperative percutaneous Doppler assessment of the LITA and RGEA grafts, performed before hospital discharge, there was a flow signal in all patients.

Operative Technique
The operations were performed without CPB, without full sternotomy, and without touching the aorta. In all cases, a small laparotomy incision was used, and the xiphoid process was resected. During the operation, the heart rate was slowed to 45 to 50 beats/min through the use of ß-blockers.

The RGEA was exposed through a small laparotomy extended by resection of the xiphoid process (Fig 2). In the last 5 patients in this series, it was expanded by a partial sternotomy 5 cm in length. The RGEA was harvested by ligating the side branches with small titanic clips (Johnson & Johnson). Its caliber, length, and free flow were estimated. The diaphragm and pericardium were incised and the RCA was explored for suitability, size, and position. If the RGEA was not long enough, it was lengthened with a saphenous vein graft. Papaverine was injected into the graft intraluminally. Heparin, 1 mg/mL, was given, and the anastomosis was performed.



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  		Operative anatomy. (LAD = left anterior descending artery; LITA = left internal thoracic artery; RCA = right coronary artery; RGEA = right gastroepiploic artery.)

 
In patients with two vessel disease, after harvesting of the RGEA and before heparinization, an anterior thoracotomy was performed by removing the fourth costal cartilage, as described by Calafiore and colleagues [10], but the pleural cavity was not opened routinely. The LITA was harvested as a skeletonized graft and the LITA-to-LAD anastomosis was performed before the RGEA anastomosis.

No special instruments for stabilization of the anastomosis site were used in this series. Stabilization was accomplished with a stay suture on one side of the donor vessel, which was placed parallel to the donor vessel. Bleeding from the anastomosis site during the anastomosis was controlled with retractor tapes placed on both sides of the site.

Coronary anastomoses were performed using either 7-0 or 8-0 continuous polypropylene sutures (Johnson & Johnson). The mean free flow as measured by Doppler echocardiography in the RGEA grafts was 37.9 mL/min (range, 10 to 78 mL/min) and that in the LITA grafts was 39.3 mL/min (range, 30 to 58 mL/min). The mean diameter of the RCA, measured by flexible probes, was 1.75 mm (range, 1.5 to 2.5 mm). All patients received prophylactic antibiotic treatment with a single dose of 500 mg of vancomycin at the induction of anesthesia.

Follow-up
A follow-up examination was performed 1 to 6 months after operation. Control angiography was performed within 3 months after operation in all patients.

Statistical Analysis
Ninety-five percent confidence intervals (CIs) for mortality, incidence of complications, and graft patency were calculated using the exact binomial distribution, and CIs for differences in median NYHA class were calculated using the Wilcoxon approach [18].


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
There was no operative or follow-up mortality (CI, 0% to 13.7%). A hemiplegia developed in 1 patient (4%) 2 weeks after operation, but it resolved completely (CI 0.1% to 20.4%). In 1 patient, transient atrial fibrillation was observed. The mean operative time was 112 minutes (range, 95 to 158 minutes) for single RGEA graft operations and 211 minutes (range, 150 to 245 minutes) for double graft operations. The mean operating room time was 209 minutes for single graft operations and 306 minutes for double graft operations. The median stay in the intensive care unit was 1 day. No blood transfusion was needed. Abnormal release of the myocardial band isomer of creatine kinase was not detected in any of our patients after operation (CI, 0% to 13.7%) (Fig 1b).

The length of the typical postoperative hospital stay ranged from 3 days to 1 week, although 1 patient had a postoperative hospitalization of 18 days because of social circumstances (Fig 1c).

At follow-up examination, 23 patients were in NYHA class I and 2 were in NYHA class II. In a comparison of the preoperative versus postoperative NYHA class, the median improvement was 1.5 classes (CI, 1.5 to 2 classes). Postoperative angiography was performed in all patients, but it was a technical failure in 2 and their angiographic graft patency could not be evaluated. In 1 patient, the RGEA could not be catheterized because of its anomalous origin from the superior mesenteric artery, and in 1 patient, angiography had to be interrupted because of extravasation of the contrast media. In both cases, the RGEA signals could be identified by percutaneous Doppler assessment and both LITA grafts were visualized before cessation of the angiography. At postoperative angiography, 19 of the 23 RGEA grafts that could be evaluated were functioning well (Fig 3). In 3 of the nonvisualized RGEA grafts, the percentage of proximal stenosis of the RCA was 40%, 50%, and 50%, respectively. These stenoses were not critical and allowed remarkable competitive flow (Table 1). All 3 of the patients with competitive flow and nonvisualized RGEA grafts were in NYHA class I after operation. All 14 of the LITA grafts were patent (see Table 1).



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  		Patent right gastroepiploic artery (RGEA) graft to the right coronary artery (RCA).

 

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  		Angiographic Graft Patency

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
Coronary artery bypass grafting has been performed using CPB with cardiac arrest for more than 20 years. The use of arterial grafts, especially anastomosis of the LITA to the LAD, has been shown to improve survival significantly and to decrease the risk of angina, myocardial infarction, and the need for redo CABG or PTCA during the postoperative follow-up period [1] [2] [19] [20]. Graft patency of the RGEA in conventional CABG repeatedly seems to be better than venous graft patency [3] [4] [5] [6] [7] [8]. However, competitive flow that occurs when coronary arteries with only moderate stenosis are bypassed with the RGEA seems to have a significant negative effect on graft patency [3] [21]. Among our patients who underwent MIDCABG, three RCAs with noncritical percentages of stenosis (up to 50%) were bypassed with the RGEA. None of these RGEA grafts could be visualized by control angiography. In these patients, the percentage of RCA stenosis was overestimated as being near the critical level by preoperative angiography.

Percutaneous transluminal coronary angioplasty challenged CABG by offering substantial advantages, including its less invasive nature. Several randomized clinical trials were performed to compare the results of CABG and PTCA, and the Bypass Angioplasty Revascularization Investigation [9] finally confirmed that CABG is better than PTCA for avoiding additional revascularization procedures and relieving angina. However, there are more in-hospital complications associated with CABG compared with PTCA. A significant improvement in the mortality rate associated with CABG compared with PTCA was observed only among patients with diabetes.

The risks associated with the use of CPB recently have been eliminated in some studies by performing CABG on the beating heart using full sternotomy [22] [23]. On the other hand, the LITA was used to perform coronary revascularization on the beating heart by coronary surgical pioneers such as Kolesov as early as 1963 [24]. However, the technically less demanding operating circumstances provided by CPB spurred a trend toward the use of cardiac arrest, despite the fact that many of its dangers still exist. Minimally invasive coronary artery bypass grafting using LITA-to-LAD anastomoses without full sternotomy and CPB has proven to be a viable alternative to conventional CABG, providing some remarkable advantages. In MIDCABG, the LITA has been used to anastomose the LAD, without CPB and with minimal operative trauma [10] [11] [15] [16]. In redo operations, the RCA has been anastomosed to the right internal thoracic artery through a right anterior thoracotomy [16] [17] or to the RGEA through a laparotomy [12]. However, when using the right internal thoracic artery, the anatomy of the RCA may restrict the patient’s suitability for MIDCABG. In our patients, the lack of a mechanical stabilizer was compensated for by the surgical assistant. However, we now routinely use a stabilizer, which clearly improves operating circumstances.

Study Limitations
Anastomosis of the RGEA to the RCA in MIDCABG is a new method, and we were learning it during the study period. Thus, the operating time was variable, and the patients were followed up in the hospital longer than would have been indicated by their clinical outcome. Still, the postoperative hospital stay was about 2 days shorter than the median of 7 days after conventional CABG. The learning curve and the lengthened postoperative hospital stay required to evaluate possible unknown complications restricted our ability to estimate the costs of MIDCABG in patients with RCA disease. These problems also would have biased the results of a randomized study. The operating time was shortened by about 30% during the study period, and we believe that a randomized study could be initiated after operating on about 40 patients. Our patient population also was limited, but we estimated the reproducibility of our results by providing CIs for our main outcome variables. The patients operated on in this study either were considered unsuitable for PTCA and coronary stent placement or had undergone PTCA and experienced restenosis or technical failure. Consequently, no comparison with PTCA or coronary stent placement could be done for these patients.

Conclusions
The MIDCABG method using RGEA grafts may be difficult to perform in obese patients, those who previously have undergone a laparotomy, or those who have an enlarged liver. The patency of the RGEA and LITA grafts was comparable with that of corresponding grafts in conventional CABG, and the number of postoperative complications seemed to be low. However, significant competitive flow in RGEA anastomoses should be avoided, as in the conventional method.

The minimal operative trauma and avoidance of CPB, with its harmful effects, results in a shorter postoperative hospital stay for patients who undergo MIDCABG. By combining MIDCABG with PTCA in the same session, three vessel disease can be treated with minimal operative trauma and probably better LAD function compared with PTCA alone [25]. The use of RGEA anastomosis expands the indications for MIDCABG, with minimal patient selection, to patients undergoing primary operations for LAD and RCA lesions.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
This study was supported by the Finnish Foundation for Cardiovascular Research and the Helsinki University Central Hospital Foundation.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Galbut DL, Traad EA, Dorman MJ, et al. Seventeen-year experience with bilateral internal mammary artery grafts. Ann Thorac Surg 1990;49:195-201.[Abstract]
  2. Lytle BW, Cosgrove DM, Saltus GL, Taylor PC, Loop FD Multivessel coronary revascularization without saphenous vein: long-term results of bilateral internal mammary artery grafting. Ann Thorac Surg 1983;36:540-547.[Abstract]
  3. Voutilainen S, Verkkala K, Järvinen A, Keto P Angiographic 5-year follow-up study of right gastroepiploic artery grafts. Ann Thorac Surg 1996;62:501-505.[Abstract/Free Full Text]
  4. 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;107:1309-1316.[Abstract/Free Full Text]
  5. Suma H, Wanibuchi Y, Terada Y, Fukuda S, Takayama T, Furuta SI The right gastroepiploic artery graft. Clinical and angiographic midterm results in 200 patients. J Thorac Cardiovasc Surg 1993;105:615-623.[Abstract]
  6. Mills NL, Hockmuth DR, Everson CT, Robart CC Right gastroepiploic artery used for coronary artery bypass grafting. Evaluation of flow characteristics and size. J Thorac Cardiovasc Surg 1993;106:579-586.[Abstract]
  7. Perrault LP, Carrier M, Hébert Y, et al. Clinical experience with the right gastroepiploic artery in coronary artery bypass grafting. Ann Thorac Surg 1993;56:1082-1084.[Abstract]
  8. Pym J, Brown PM, Pearson M, Parker J Right gastroepiploic-to-coronary artery bypass. The first decade of use. Circulation 1995;92(Suppl 2):45-49.[Abstract/Free Full Text]
  9. The Bypass Angioplasty Revascularization Investigation (BARI) investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996;335:217-225.[Abstract/Free Full Text]
  10. Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
  11. Calafiore AM, Angelini GD Left anterior small thoracotomy (LAST) for coronary artery revascularisation. Lancet 1996;347:263-264.[Medline]
  12. Grandjean JG, Mariani MA, Ebels T Coronary reoperation via small laparotomy using right gastroepiploic artery without CPB. Ann Thorac Surg 1996;61:1853-1855.[Abstract/Free Full Text]
  13. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135-137.[Abstract/Free Full Text]
  14. Suma H, Kigawa I, Horii T, Tanaka J, Fukuda S, Wanibuchi Y Coronary artery reoperation through the left thoracotomy with hypothermic circulatory arrest. Ann Thorac Surg 1995;60:1063-1066.[Abstract/Free Full Text]
  15. Stanbridge RDeL, Symons GV, Banwell PE. Minimal-access surgery for coronary artery revascularization. Lancet 1995;346:837.[Medline]
  16. Subramanian VA, Sani G, Benetti FJ, Calafiore AM Minimally invasive coronary bypass surgery: a multi-center report of preliminary clinical experience. Circulation 1995;92(Suppl 2):645.
  17. Uppal R, Wolfe WG, Lowe JE, Smith PK Right thoracotomy for reoperative right coronary artery bypass procedures. Ann Thorac Surg 1994;57:123-125.[Abstract] Gardner MJ, Altman DG. Statistics with confidence. Br Med J 1989;28–30, 71–9.
  18. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on ten-year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Abstract]
  19. Lytle BW, Loop FD, Cosgrove DM, et al. Fifteen hundred coronary reoperations. J Thorac Cardiovasc Surg 1987;93:847-859.[Abstract]
  20. Uchida N, Kawaue Y Flow competition of the right gastroepiploic artery graft in coronary revascularization. Ann Thorac Surg 1996;62:1342-1346.[Abstract/Free Full Text]
  21. Buffolo E, Andrade JCS, Branco JNR, Teles CA, Aquiar LF, Gomes WJ Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
  22. Pfister AJ, Zaki MS, Garcia JM, et al. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992;54:1085-1092.[Abstract]
  23. Kolesov VI Mammary artery–coronary artery anastomosis as method of treatment for angina pectoris. J Thorac Cardiovasc Surg 1967;54:535-544.[Medline]
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