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Ann Thorac Surg 2001;71:1013-1014
© 2001 The Society of Thoracic Surgeons

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Case report

The left gastric artery as an in-situ conduit in coronary artery bypass grafting

^a Department of Cardiothoracic Surgery, Heart-Lung Institute, University Medical Center Utrecht, Utrecht, The Netherlands
^b Department of Cardiology, Heart-Lung Institute, University Medical Center Utrecht, Utrecht, The Netherlands

Accepted for publication February 1, 2000.

Address reprint requests to Dr van Aarnhem, Klinik für Herzchirurgie, Herzzentrum Leipzig, Russenstrasse 19, 04289 Leipzig, Germany
e-mail: evanaarnhem{at}hotmail.com

	Abstract

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Unsuitability of the in-situ right gastroepiploic artery in coronary bypass grafting occurs. Sometimes free-grafting can be performed, although this should not be considered in patients with a diseased ascending aorta. We describe the successful use of the left gastric artery as an alternative in-situ arterial conduit in a patient with a severely atherosclerotic ascending aorta.

	Introduction

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Arterial grafting in situ is the treatment of first choice in coronary artery bypass grafting (CABG) [1]. In a selected group of patients the procedure can be performed without extracorporeal circulation through a full sternotomy or a minimal invasive access, ie, left anterior thoracotomy or subxiphoid incision [2]. Additionally this allows a no-touch technique of the ascending aorta.

In isolated right coronary artery (RCA) disease, off-pump revascularization of the inferior myocardial wall through a subxiphoid incision is attractive, using the in-situ right gastroepiploic artery (RGEA). However, sometimes this conduit appears not to be suitable due to its anatomic position or the absence of adequate flow [3]. In this report we describe the successful use of the left gastric artery (LGA) as an alternative in-situ conduit to the RGEA in an off-pump CABG procedure of the RCA.

A 78-year-old woman had previously undergone a percutaneous transluminal coronary angioplasty and stenting of the left anterior descending coronary artery. She was admitted because of recurrent severe anginal complaints (class IV according to the Canadian Cardiovascular Society). Cardiac catheterization showed complete occlusion of the RCA with retrograde filling from a normal left descending coronary artery. Myocardial scintigraphy revealed a reversible defect in the inferior wall. At physical examination a mild systolic murmur was heard due to aortic sclerosis. The chest roentgenogram showed severe and extensive calcification of the ascending aorta, requiring a "no-touch" procedure, whenever possible.

Off-pump grafting of the RCA was planned through limited subxiphoid access with the use of an in-situ RGEA. However after opening the peritoneum this conduit could not be used because of its caudal position due to a ptosis of the stomach. The LGA was positioned more craniad and therefore was easily accessible. The artery was prepared for use as an in-situ graft and harvested in the skeletonized way along the minor curvature of the stomach up to the level of the proper hepatic artery, where it was dissected. Special care was taken to preserve the left gastric plexus and the vagal gastric branches to the pylorus. The LGA was then introduced into the pericardial cavity through a 2-cm incision in the diaphragm. The free flow of the conduit was 18 mL/min. Immobilization and exposure of the myocardial target area was achieved with the Octopus I tissue stabilizer (Medtronic, Minneapolis, MN) attached to the operating table. The anastomosis was performed using a 8-0 polypropylene running suture. Coronary occlusion time was 8 minutes. At functional testing of the anastomosis a good bifasic Doppler flow could be heard.

The postoperative course of the patient was uneventful and on day 5 a repeat angiography showed a fully patent anastomosis (Fig 1). The patient was discharged on day 6. At 1-year follow-up she is free of anginal complaints.

View larger version (164K): [in this window] [in a new window]   Fig 1. Postoperative angiography at 5 days showing the left gastric artery (1) with a fully patent anastomosis (2) on the distal right coronary artery (3).

	Comment

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Recently Grandjean and colleagues [4] reported impracticability of an in-situ RGEA occurring in up to 4% of patients. Half of the conduits were too small and in the other half it was decided to use the RGEA as a free graft. In our patient the RGEA could not be used as an in-situ graft because of its unfavorable position due to a ptosis of the stomach. Free grafting was not considered because of the extensively calcified ascending aorta and its obvious risks.

The well-developed LGA, however, was easily detected. The artery is one of the branches of the celiac trunk and runs within the lesser omentum along the minor curvature, finally it anastomoses with the right gastric branch of the proper hepatic artery. In contrast to a pedicled RGEA, the vessel should be harvested in the skeletonized way. This preserves the left gastric plexus and its joining vagal branches along the lesser curvature, which innervate the pyloric sphincter. Similar to the RGEA, gentle manipulation and the eventual use of vasodilative agents should be contemplated for this nonelastic artery.

The use of the LGA to only mildly stenosed (50–70%), large right coronary arteries should not be considered. The blood supply may be insufficient, leading to hypoperfusion of the myocardium. Especially in off-pump revascularizations ischemia during the procedure might occur, even with hemodynamic deterioration [5]. Edwards and colleagues [6] considered already in 1973 the use of the LGA for arterial revascularization of the RCA but found it too short and too small. In our patient the favorable presentation of the LGA made it very suitable to serve as an alternative coronary artery bypass conduit. According to the intraoperative functional testing and the repeat angiography the bypass performs well, so it enabled us to complete a bypass surgery procedure off-pump as well as through minimal access.

In conclusion, the LGA can be considered as a valuable alternative in-situ arterial conduit for inferior myocardial wall revascularization in both off- and on-pump CABG in the absence of a useful RGEA.

	References

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1. Lytle B.W., Blackstone E.H., Loop F.D., et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 1999;117:855-872.[Abstract/Free Full Text]
2. Subramanian V.A., McCabe J.C., Geller C.M. Minimally invasive direct coronary artery bypass grafting: two-year clinical experience. Ann Thorac Surg 1997;64:1648-1655.[Abstract/Free Full Text]
3. Suma H. Optimal use of the gastroepiploic artery. Semin Thorac Cardiovasc Surg 1996;8:24-28.[Medline]
4. Grandjean J.G., Voors A.A., Boonstra P.W., Den Heyer P., Ebels T. Exclusive use of arterial grafts in coronary artery bypass operations for three-vessel disease: use of both thoracic arteries and the gastroepiploic artery in 256 consecutive patients. J Thorac Cardiovasc Surg 1996;112:935-942.[Abstract/Free Full Text]
5. Van Aarnhem E.E.H.L., Nierich A.P., Jansen E.W.L. When and how to shunt the coronary circulation in off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg 1999;16(Suppl 2):S2-S6.[Abstract/Free Full Text]
6. Edwards W.S., Lewis C.E., Blakely W.R., Napolitano L. Coronary artery bypass with internal mammary and splenic artery grafts. Ann Thorac Surg 1973;15:35-40.[Medline]

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This Article Abstract Full Text (PDF) 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): Egidius E.H.L. van Aarnhem Erik W.L. Jansen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by van Aarnhem, E. E.H.L. Articles by Jansen, E. W.L. Search for Related Content PubMed PubMed Citation Articles by van Aarnhem, E. E.H.L. Articles by Jansen, E. W.L. Related Collections Coronary disease