Ann Thorac Surg 1999;68:2328-2329
© 1999 The Society of Thoracic Surgeons
Case Reports
Severe diffuse atherosclerotic lesions of right gastroepiploic artery graft
Toshiya Koyanagi, MDa,
Shunei Kyo, MDa,
Ryozo Omoto, MDa,
Shin-ichi Ban, MDb,
Motohide Takahama, MDb
a Department of Surgery, Saitama Medical School, Saitama, Japan
b Department of Pathology, Saitama Medical School, Saitama, Japan
Address reprint requests to Dr Koyanagi, Sakakibara Memorial Hospital, 2-5-4 Yoyogi, Shibuyaku, 151-0053 Tokyo, Japan
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Abstract
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The incidence of arteriosclerosis of the right gastroepiploic artery (RGEA) has not been widely known. We experienced one patient in whom the RGEA had severe diffuse atherosclerotic lesions and luminal narrowing, and was therefore determined to be unsuitable as a coronary bypass conduit at operation.
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Introduction
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The right gastroepiploic artery (RGEA) is commonly used as an alternative or adjunct to internal thoracic artery (ITA) graft for coronary artery bypass grafting. It is reported that the RGEA has slightly more intimal thickening than ITA, but significant luminal narrowing caused by arteriosclerosis is rare. We report the case of a patient having the RGEA with severe diffuse atherosclerotic lesions and luminal narrowing.
A 66-year-old man was admitted with unstable angina, having severe coronary artery disease involving three vessels. He had no coexistent carotid artery disease or arteriosclerosis obliterans, and had no history of gastropathy. We planned to perform myocardial revascularization using the left internal thoracic artery (LITA) and the RGEA, but neither vessel was examined by preoperative angiography. Both the LITA and the RGEA were harvested at operation. After heparinization, the distal RGEA was divided and dilated by intraluminal injection of diluted papaverine. Although the blood flow through the RGEA initially appeared to be low, free flow did not flush at all after cardiopulmonary bypass started. Moreover, the sclerotic lesions were palpable along the RGEA; therefore, we abandoned use of the RGEA. The LITA was anastomosed to the left anterior descending artery and the saphenous vein graft as a sequential bypass to the posterolateral and posterodescending branches of the circumflex artery. The postoperative course was uncomplicated. The LITA was revealed by postoperative angiography to be patent with no irregularity. Macroscopically, the RGEA was dotted with multiple, diffuse atheromatous plaques in the intima (Fig 1), and histological findings showed significant luminal thickening and intimal narrowing (Fig 2).
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Fig 1. Macroscopically, the right gastroepiploic artery (RGEA) was dotted with multiple, diffuse atheromatous plaques in the intima.
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Comment
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The prevalence of arteriosclerosis of the RGEA has not been widely investigated. Larsen and associates examined the incidence of arteriosclerosis in the gastric and various extragastric vessels in 103 autopsied patients who had lived longer than 60 years. It was concluded that the gastroduodenal artery, upstream of the RGEA that branches from the common hepatic artery, apparently has less arteriosclerosis than the coronary arteries [1]. Suma and associates reported that the RGEA has slightly more intimal thickening than the ITA, but significant luminal narrowing caused by arteriosclerosis is rare. However, one RGEA out of 35 (3%) showed overt arteriosclerosis in a patient with associated aortoiliac occlusive disease [2]. Carrel and associates presented a case report of arteriosclerotic lesions of the RGEA. A 63-year-old patient underwent myocardial revascularization of the RGEA. Angiography 3 months after the operation showed a 50% to 75% stenosis in the proximal segment of the RGEA. Percutaneous transluminal angioplasty for the stenotic lesion resulted in successful dilation. Furthermore, they assessed the incidence, severity, and extent of atherosclerotic changes in the RGEA by postmortem examination. As a result, 4 out of 37 patients (11%) were found to have an RGEA stenosis greater than 50%, and intimal thickening with up to 50% stenosis of the RGEA was seen in 89% of cases [3]. Malhotra and associates reported that histologic examination of the RGEA showed more defects in continuity of internal elastic lamina and abundant smooth muscle cells in the media than the ITA [4]. Sims and associates reported that discontinuity of the internal elastic lamina causes migration of smooth muscle cells from the media to the intima and triggers atherosclerosis [5]. This may increase the incidence of atherosclerosis of the RGEA as compared with the ITA [4]. Mills and associates reported that in one patient, the RGEA had visible nonobstructive atherosclerosis that did not cause significant intraluminal stenosis, but the graft was used with free flow of 98 mL/min because of scarcity of available conduits. Therefore, preoperative assessment of the RGEA [6] by angiography may be recommended, at least in high-risk procedures. In addition, if free flow of the RGEA is poor at operation, atherosclerotic narrowing should be taken into consideration, excluding spasm. Palpation of the RGEA is required during the operation, though it may induce spasm.
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References
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Larsen E., Johansen A.A., Andersen D. Gastric arteriosclerosis in elderly people. Scand J Gastroenterol 1969;4:387-389.[Medline]
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Suma H., Takanashi R. Arteriosclerosis of the gastroepiploic and internal thoracic arteries. Ann Thorac Surg 1990;50:413-416.[Abstract/Free Full Text]
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Carrel T., Ammann F., Schneider J., Domeisen H., Turina M.I. Atherosclerotic lesions of the gastroepiploic artery. J Thorac Cardiovasc Surg 1995;110:1768-1770.[Free Full Text]
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Malhotra R.M., Bedi H.S., Bazaz S., Jain S., Trehan N. Morphometric analysis of the right gastroepiploic artery and the internal mammary artery. Ann Thorac Surg 1996;61:124-127.[Abstract/Free Full Text]
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Sims F.H. Discontinuities in the internal elastic lamina; a comparison of coronary and internal mammary arteries. Artery 1985;13:127-142.[Medline]
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Mills N.L., Hockmuth D.R., Everson C.T., Robert C.C. Right gastroepiploic artery used for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1993;106:579-586.[Abstract]
Accepted for publication April 28, 1999.
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Abstract
Introduction
