| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2001;72:2184
© 2001 The Society of Thoracic Surgeons
a Grenoble University Hospital, Service de Chirurgie Cardiaque, CHU Grenoble, BP 217 Grenoble Cedex 9, France
e-mail: ochavanon{at}chu-grenoble.fr
To the Editor
We have read with great interest the article by Dr Yasuura and colleagues [1] on a theoretical model analysis of the gastroepiploic artery (GEA) graft flow. It is an important article that corroborates our clinical impression on this graft in terms of potential limited flow reserve and possible flow competition. Because this can lead to a physiologically nonfunctioning bypass graft if some conditions are not respected for its clinical use, we agree with conclusion of this article and do not hesitate to sacrifice the GEA if it is not satisfactory.
The superiority of arterial grafts for myocardial revascularization has progressively led surgeons to common use of the internal thoracic artery (ITA) and increasingly frequent use of the GEA to reach coronary arteries on the inferior ventricular wall [2]. Other theoretical advantages of this conduit are that it is a pedicled graft not requiring reimplantation and lateral aortic cross clamping and is harvested in about 15 minutes, with only a few centimeters more at the low part of sternotomy. This arterial conduit is classically considered a suitable graft for coronary artery bypass grafting because of its similarity to the ITA in terms of diameter, flow, and atherosclerosis, although intimal thickening may be slightly greater in the GEA [3]. The main GEA drawback concerns the flow. For this reason, both degree of stenosis of the right coronary artery and size of the GEA graft are very important factors relative to the recipient coronary artery, to avoid flow competition with the recipient artery, as emphasized by Yasuura and colleagues [1]. Consequently, the GEA should be used first, only in cases of thrombosed or very tight stenosis of the RCA, and second, if its diameter is large enough for the recipient coronary artery. Furthermore, because of its muscular histologic status, the GEA is a highly vasoactive artery that is prone to spasm, requiring adequate preparation with papaverine sprayed on the pedicled graft, as previously described by our team [4].
Since this publication we have modified our technique with distal placement of a metal clip allowing maximal dilation of the conduit due to the combined effect of papaverine and of the mechanical effect induced by arterial pressure. The pedicle is cut at the last moment either before dissection of the coronary artery, in beating heart surgery, or before starting the cardiopulmonary bypass in on-pump operations. In spite of this careful preparation, if the graft is not satisfactory it is immediately sacrificed.
Since 1990, we have used 1,072 GEAs in our institution among 3,888 coronary artery bypass grafts. All procedures were performed through a median sternotomy. After internal thoracic artery harvesting, spreading the sternum and opening the pericardium, target coronary vessels are explored to confirm the recipient vessel, particularly when the right coronary artery is thrombosed on angiography. Then the GEA is dissected on a pedicle from the pylorus to the middle of the greater curvature of the stomach using metal ligature clips, and is brought up anteriorly.
We reviewed our GEA experience last year (January 2000 to December 31, 2000) to assess the availability of this graft. Among 201 patients operated for a coronary artery bypass graft by one surgeon (O.C.), 137 patients had coronary artery bypass grafts to the right coronary territory. The GEA was supposed to be used for 67 of these patients (49%), but in 11 patients (16.4%) it could not be used; in 9 patients, the GEA was too small at the location of anastomosis, and in 2 patients it was atheromatous, with severe calcification in 1 patient. The surgical strategy was modified by using a saphenous vein graft in all but 1 patient (requiring a free right internal thoracic artery). During the same period, no internal thoracic mammary artery was discarded.
In conclusion, the GEA may be used as a graft in the vast majority of patients provided that it is carefully harvested and prepared. However, the GEA should be discarded without hesitation if it is not suitable.
We wish to thank Dr E. Colle for revision of this letter.
References
Related Article
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
