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Ann Thorac Surg 2000;69:728-731
© 2000 The Society of Thoracic Surgeons

Original Articles

Theoretical analysis of right gastroepiploic artery grafting to right coronary artery

Kenzo Yasuura, MDa, Yasushi Takagi, MDa, Yasuhisa Ohara, MDa, Yoshiyuki Takami, MDa, Akio Matsuura, MDa, Hiroshi Okamoto, MDa

a Department of Thoracic Surgery, Nagoya University School of Medicine, Nagoya, Japan

Address reprint requests to Dr Yasuura, Chuoudai 6-11-14, Kasugai City, Aichi 487-0011, Japan


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. The right gastroepiploic artery (GEA) has been used as the second reliable arterial graft for coronary artery bypass grafting (CABG). However, concern regarding the flow competition with the recipient coronary artery has remained.

Methods. An application of in situ GEA grafting to the right coronary artery (RCA) was studied by using a theoretical model. The theoretical model of CABG was given variables; ie, the diameters and the lengths of both in situ GEA and proximal segment of the RCA, and the degree of proximal stenosis in the RCA. According to the range of these variables obtained from clinical data, the ratio of the GEA flow to the flow of the RCA distal to the anastomosis was calculated.

Results. Main factors to determine the flows in the two parallel paths were the inner diameters of both vessels, and the degree of the proximal stenosis. When the inner diameters of the GEA were 0.5 mm larger than that of the RCA, the GEA carried more than 50% of the total flow of the RCA distal to the anastomosis despite a moderate stenosis in the RCA. When the inner diameter of the GEA was equal to, or 0.5 mm smaller than, that of the RCA, the GEA flow was dominated by the native RCA flow unless the proximal stenosis was critical.

Conclusions. If the inner diameter of the GEA is 0.5 mm larger than that of the RCA, CABG with the GEA can be applied more widely. If not, the application would basically be limited.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
For better graft patency in the long term, there has been routine use of multiple arterial grafts for coronary artery bypass grafting (CABG) [1]. As in situ arterial grafts, the right gastroepiploic artery (GEA) is secondary to the internal thoracic artery (ITA) [2]. Whereas the patency rate of in situ right ITA grafts bypassed to the right coronary artery (RCA) has been considerably lower, in situ GEA grafts offer satisfactory midterm patency and are regarded as more reliable than right ITA [3, 4]. The in situ GEA graft is also preferred to the radial artery graft, because of histologic superiority [5], and an avoidance of technical difficulty associated with a proximal anastomosis.

However, the GEA has two noteworthy characteristics in comparison with the ITA. One is the spasms associated with histologic distinction. Stronger spasm in the use of the GEA during operation is often encountered, and for prevention, topical use of papaverine and a systemic dose of nitroglycerin or calcium channel blockers are required [4]. Another characteristic is a limited flow reserve. The GEA branches off from a more distal portion of the aorta, is longer than the ITA, and varies more widely in diameter among patients, and hence it often causes a limited flow reserve. In regard to the use of in situ arterial grafts, if the proximal stenosis in the recipient coronary artery is marginal, postoperative angiography often shows "distal thread phenomenon" or "string sign" in ITA grafts and "thinning down phenomenon" in GEA grafts, leading to graft occlusion [6–8]. Flow competition between the GEA and the recipient coronary artery has been discussed, and the indications for use of the GEA in CABG remains controversial.

In this study, to clarify the indications of in situ GEA to the RCA as a bypass graft, we analyzed the effects of the lengths and the diameters of both the GEA and the proximal segment of the RCA, and the degree of proximal stenosis in the RCA on the ratio of the GEA flow to the flow of the RCA distal to the anastomosis under various conditions by using a theoretical model of the bypass system.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Theoretical model of the bypass system
For the purpose of analysis, a theoretical investigation is made with reference to previous studies [9, 10]. The theoretical model of the bypass system is illustrated in Figure 1. In this analysis, it was assumed that: (1) all the vessel segments had a steady blood flow, (2) the GEA and the RCA had an even inner diameter each, (3) the proximal stenosis in the RCA was 3 mm long, and (4) the length of GEA was assumed to be from its origin at the gastroduodenal artery to the anastomotic site. For the purpose of simplicity, the energy loss by the turbulent flows at the inlets and outlets and the shearing stresses were disregarded. The resistance to blood flow of both the GEA and the proximal segment of the RCA was calculated by using Poiseuille’s law (resistance = length/diameter4). Taken into account as the determining factors of the percentage flow through the GEA were the inner diameters of both vessels, the lengths of the GEA, the proximal segment of the RCA, and the degree of proximal stenosis in the RCA. The respective contributions to the total flow of the RCA distal to the anastomosis is given by the following equation:

where Qd is the total flow of the RCA distal to the anastomosis, Qg is the flow of the GEA, and Qc is the flow of the proximal segment of the RCA. The resistance to flow in the parallel paths is given as follows:




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  		Fig 1. Theoretical model for mathematical concept. Two paths stem from the aorta in parallel. (Ao = aorta; CA = right coronary artery (RCA); GEA = gastroepiploic artery; Lg = length of GEA pedicle; Lc = length of coronary artery from origin to anastomotic site; Ls = length of stenotic lesion (3 mm); Dg = diameter of GEA; Dc = diameter of RCA; Ds = diameter of stenotic lesion.)

 
where Rg and Rc are the resistance to the flow in the GEA and the proximal segment of the RCA; Lg, Lc, and Ls are the length of GEA pedicle, the proximal segment of the RCA, and the proximal stenosis in the RCA, respectively; and Dg, Dc, and Ds are the inner diameters of the GEA, the RCA, and the stenotic segment, respectively. Ds was set at 0.2, 0.4, 0.5, 0.8, and 1.0 mm, and percent cross-sectional stenosis in the RCA is:

From continuity, the flow in the GEA and native coronary artery combine to the total flow of the RCA distal to the anastomosis, and the source pressure of the two paths are the same:

accordingly:


Clinical data
From January 1995 to December 1997, the in situ GEA was used for primary CABG in 26 patients. They were 24 males and 2 females, with a mean age of 60.3 years, and an average body surface area of 1.6 m2. Intraoperative data concerning both vessels showed that the length of their GEA pedicles were 15 to 20 cm, their Dg, measured with probes that were sized in 0.5 mm increments, were 1.5 to 2.5 mm, and Dc were 1.5 to 2.0 mm. The sites of their anastomoses ranged from the distal portion of the RCA to the posterior descending artery. According to these data, Lg for the calculation was set at 15, 17, and 19 cm; Dg at 1.5, 2.0, and 2.5 mm; Dc again at 1.5 and 2.0 mm; and Lc at 10 and 15 cm, which correspond to the distal portion of the RCA and the posterior descending artery, respectively. These values can be applied to the equations based on the theoretical model to calculate the ratio of flow through the GEA to the RCA flow distal to the anastomosis (Qg/Qd).


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
We found that the diameters of the GEA and the RCA (Dg and Dc) and the degree of proximal stenosis mainly influenced the ratio of the GEA flow to the flow of RCA distal to the anastomosis (Qg/Qd). The length of the GEA (Lg) and the proximal segment of the RCA (Lc) had small effects on the dominant flow through the GEA. The relationship between the ratio of the GEA flow to the flow of RCA distal to the anastomosis (Qg/Qd) and the degree of proximal stenosis in terms of cross-sectional area are shown in Figures 2 to 5.



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  		Fig 2. The diameters of the GEA and the RCA are 2.5 and 2.0 mm, respectively. (Left) The GEA is assumed to be bypassed to the distal portion of the RCA (Lc = 10 cm). As the GEA has the larger caliber, compared with the RCA, the GEA can provide more than 50% of the total flow of the RCA distal to the anastomosis. The GEA flow dominates the flow of the proximal segment of the RCA even in the range of low degrees of stenosis. (Right) If anastomosed distally (Lc = 15 cm), the GEA is assumed to be bypassed to the posterior descending artery.

 
In this mathematical model, we assumed that if the ratio of flow through the GEA to the RCA flow distal to the anastomosis (Qg/Qd) was more than 50%, the flow of the GEA (Qg) was dominant over that of the proximal segment of the RCA (Qc). As shown in Figure 2, when Dg and Dc were 2.5 and 2.0 mm, respectively, the GEA flow (Qg) overwhelmingly dominated the flow of proximal segment of the RCA (Qc), even if the proximal stenosis is moderate. Similarly, in a case where Dg and Dc were 2.0 and 1.5 mm, respectively, the result was much the same (Fig 3). These results suggest the in situ GEA can be broadly applied as a functional arterial graft under such circumstances.



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  		Fig 3. The diameters of the GEA and the RCA are 2.0 and 1.5 mm, respectively. The relation of the diameters of both the GEA and the RCA with the proximal stenosis is nearly the same as in Figure 2. The GEA can provide more than 50% of the total flow of the RCA distal to the anastomosis, even in the range of low degrees of stenosis.

 
In contrast, when Dg and Dc were 1.5 and 2.0 mm, respectively, on condition that the GEA pedicle (Lg) is longer than 15 cm, the GEA flow (Qg) could not become dominant over the flow of the proximal segment of the RCA (Qc), even if 91% cross-sectional stenosis, equivalent to 70% reduction in luminal diameter, was present. It made little difference where the anastomotic site was selected (Fig 4). These data also suggest the shortest routing of the GEA can be effective for prevention of flow competition under such conditions [11].



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  		Fig 4. The diameters of the GEA and the RCA are 1.5 and 2.0 mm, respectively. Even if the anastomotic site is proximal or distal, the GEA flow is dominated by the flow of the proximal segment of the RCA in the range of up to 91% cross-sectional stenosis, except for the shortest graft (Lg = 15 cm). The flow of the proximal segment of the RCA dominates that of the GEA unless the proximal stenosis in the RCA is severe.

 
When both Dg and Dc were both 2.0 mm and the anastomotic site was distal (Lc = 15 cm), the GEA flow (Qg) could be dominant in the range of more than 75% cross-sectional stenosis, equivalent to 50% stenosis in luminal diameter. However, if proximally anastomosed under these circumstances (Lc = 10 cm), the GEA flow (Qg) could not be dominant under the same degree of stenosis (Fig 5). Namely, on condition that Dg and Dc are the same size, it is important to select a distal site for anastomosis to prevent the flow competition if the obstructive lesion is properly located and morphologic suitability for anastomosis is allowed.



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  		Fig 5. The diameters of both the GEA and the RCA are 2.0 mm. (Left) When anastomosed proximally, the flow through the GEA can dominate that of the proximal segment of the RCA in the range of more than 84% of proximal stenosis. (Right) However, when distally anastomosed, the GEA flow can dominate in the range of more than 75% of proximal stenosis.

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
As the superior long-term performance of an arterial graft such as the ITA, the GEA is being applied more often as the second reliable arterial graft because of the low prevalence of atherosclerosis [12]. However, in situ arterial grafts have been questioned regarding their flow capacity because the diameters of their vessels are smaller than that of the saphenous vein and they branch off from a more distal portion of the aorta. Therefore, if there occurs a flow competition between the anastomosed graft and the recipient coronary artery, it might result in graft occlusion [8].

Previous studies [9, 13] demonstrated that a bypass graft to a nonobstructed coronary artery does not increase the distal coronary flow, which arises from the proximal coronary artery and the bypass graft. Accordingly, there is an inverse relationship between the magnitude of flow arising from these two sources: the larger the native coronary flow, the less the bypass graft flow, and vice versa [10]. These considerations correspond with the fact that the arterial grafts are anatomically patent but physiologically nonfunctioning if the proximal stenosis in the recipient coronary artery is marginal [14]. The influence of the competitive flow on prognosis of the arterial graft has remained obscure. However, in regard to the ITA, the occluded graft immediately after operation was demonstrated to be patent when progression of disease in the recipient coronary artery occurred [15]. This report suggested the physiological adaptability of in situ ITA.

On the other hand, the GEA is the fourth branch of the aorta, whereas the left ITA is the second branch. Clinical investigations [16, 17] suggested that the pressure pattern of the GEA was different from that of the ITA and, consequently, flow competition may be by far more prone to occur. Particularly, in contrast with in situ ITA, there has been no report concerning restoration of patency in the occluded GEA with progressive change in the recipient coronary artery. Mills and colleagues [18] concluded that a setting with possible competition of flow should be avoided with in situ GEA grafts. If the flow competition associated with the use of in situ GEA is confirmed to be a major factor of occlusion for a long-term period, these results may point to the selection of grafts. Nevertheless, little investigation has been conducted concerning the strict indication of in situ GEA. In experimental animal studies, the size and the length of both grafts and the native coronary artery are so different from those of humans, that the results can not be applied to clinical practice. Our study, based on a mathematical model, makes for the first time the indication of in situ GEA for the revascularization of the RCA clear quantitatively. It suggests that the diameter of both vessels and the degree of proximal stenosis in the RCA are the major factors to determine whether the GEA flow becomes dominant over the flow of the proximal segment of the RCA. When the diameter of the GEA is 0.5 mm larger than that of the RCA, the GEA can be available even in moderate stenosis in the RCA, whether the GEA is longer or not, and the anastomitic site is distal or proximal. Therefore, the GEA can be widely used as a graft of choice. On the contrary, when the diameters of the GEA are smaller than that of the RCA, or the same, the indication of the in situ GEA graft should be strictly limited. In addition to such circumstances, if the proximal stenosis is not severe, a free GEA grafting may well be used.

Voutilainen and colleagues [19] reported that postoperative good function of GEA grafts had a significant correlation with the proximal stenosis. Hashimoto and colleagues [17] also demonstrated that stenosis more than 60% in diameter in the recipient artery is a critical line between functioning and nonfunctioning arterial grafts. These clinical reports are consistent with our conclusions calculated from a theoretical model. Review of abdominal angiograms in 202 cases showed that 152 cases (76%) have a diameter greater than 2.0 mm at the portion 20 cm distant from the origin of the GEA [20]. Therefore, the GEA may not always be indicated as an ideal bypass conduit if the criteria for use of the GEA are dependent on our theoretical model.

Our study also demonstrates that it is important to accurately measure the diameter of both vessels, and assess the degree of proximal stenosis in the RCA by preoperative angiography.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Bergsma T.M., Grandjean J.G., Voors A.A., Boonstra P.W., Den Heyer P., Ebels T. Low recurrence of angina pectoris after coronary artery graft with bilateral internal thoracic and right gastroepiploic arteries. Circulation 1998;97:2402-2405.[Abstract/Free Full Text]
  2. Suma H., Fukumoto H., Takeuchi A. Coronary artery bypass grafting by utilizing in situ right gastroepiploic artery. Ann Thorac Surg 1987;44:394-397.[Abstract]
  3. Dietl C.A., Benoit C.H., Gilbert C.L., et al. Which is the graft for choice for the right coronary and posterior descending arteries? Comparison of the right internal mammary artery and the right gastroepiploic artery. Circulation 1995;92(Suppl II):92-97.[Abstract/Free Full Text]
  4. Pym J., Brown P., Pearson M., Parker J. Right gastroepiploic-to-coronary artery bypass. Circulation 1995;92(Suppl II):45-49.[Abstract/Free Full Text]
  5. Van Son J.A.M., Smedts F., Vincent J.G., van Lier H.J.J., Kubat K. Comparative anatomic studies of various arterial conduits for myocardial revascularization. J Thorac Cardiovasc Surg 1990;99:703-707.[Abstract]
  6. Nakao T., Kawaue Y. Effect of coronary revascularization with the right gastroepiploic artery. J Thorac Cardiovasc Surg 1993;106:149-153.[Abstract]
  7. Geha A.S., Baue A.E. Early and late results of coronary revascularization with saphenous vein and internal mammary artery grafts. Am J Surg 1979;137:456-463.[Medline]
  8. Ivert T., Huttunen K., Landou C., Bjork V.O. Angiographic studies of internal mammary artery grafts 11 years after coronary artery bypass grafting. J Thorac Cardiovasc Surg 1988;96:1-12.[Abstract]
  9. Furuse A., Klopp E.H., Brawley R.K., Gott V.L. Hemodynamics of aorta-to-coronary artery bypass. Ann Thorac Surg 1972;14:282-293.[Medline]
  10. Overton J.B., Smith J.C., Robel S.B., Spencer M.P., Mansfield P.B., Sauvage L.R. Origin of downstream flow in nonobstructed coronary arteries. Arch Surg 1973;107:764-770.[Abstract/Free Full Text]
  11. Tavilla G., Van Son J.A.M., Verhagen A.F., Smedts F. Retrogastric versus antegastric routing and histology of the right gastroepiploic artery. Ann Thorac Surg 1992;53:1057-1061.[Abstract]
  12. Larsen E., Johansen A., Andersen D. Gastric arteriosclerosis in elderly people. Scand J Gastroenterol 1969;4:387-389.[Medline]
  13. Kakos G., Oldham H.N., Jr, Dixon S.H., Jr, Davis R.W., Hagen P.O., Sabiston D.C. Coronary artery hemodynamics after aorto-coronary artery vein bypass. J Thorac Cardiovasc Surg 1972;63:849-853.[Medline]
  14. Barner H.B. Double internal mammary-coronary artery bypass. Arch Surg 1974;109:627-630.[Abstract/Free Full Text]
  15. Dincer B., Barner H.B. The "occluded" internal mammary artery graft. J Thorac Cardiovasc Surg 1983;85:318-320.[Medline]
  16. Tedoriya T., Kawasuji M., Sakakibara N., Ueyama K., Watanabe Y. Pressure characteristics in arterial grafts for coronary bypass surgery. Cardiovasc Surg 1995;3:381-385.[Medline]
  17. Hashimoto H., Isshiki T., Ikari Y., et al. Effects of competitive blood flow on arterial graft patency and diameter. Medium-term postoperative follow-up. J Thorac Cardiovasc Surg 1996;111:399-407.[Abstract/Free Full Text]
  18. Mills N.L., Hockmuth D.R., Everson C.T., Robart C.C. Right gastroepiploic artery used for coronary artery bypass grafting. Evaluation of flow characteristics and size. J Thorac Cardiovasc Surg 1993;106:579-586.[Abstract]
  19. Voutilainen S., Verkkala K., Jarvinen 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]
  20. Saito T., Suma H., Terada Y., Wanibuchi Y., Fukuda S., Furuta S. Availability of the in situ right gastroepiploic artery for coronary artery bypass. Ann Thorac Surg 1992;53:266-268.[Abstract]
Accepted for publication July 19, 1999.




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