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Ann Thorac Surg 2004;77:794-799
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Long-term follow-up of coronary artery bypass grafting in three-vessel disease using exclusively pedicled bilateral internal thoracic and right gastroepiploic arteries

^a Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands

Accepted for publication August 13, 2003.

^* Address reprint requests to Dr Tavilla, Department of Cardiothoracic Surgery, Leiden University Medical Center, K6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
e-mail: gtavilla{at}lumc.nl

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
BACKGROUND: Considerable data now exist that show that coronary artery bypass grafting with bilateral internal thoracic artery (ITA) grafts produce better outcomes than the use of a single ITA graft. The benefit of a third arterial graft has been less well established. Therefore this article describes the survival and cardiac-related event-free survival in patients having bilateral ITA and gastroepiploic artery (GEA) grafting for 3–vessel disease.

METHODS: From November 1992 to May 2002, 201 patients (mean age 53 ± 7 years) presented with 3-vessel disease and received exclusively bilateral internal thoracic (ITAs) and right gastroepiploic (GEA) arteries as pedicled grafts for coronary artery bypass procedure. Twenty-seven (13%) patients were not elective, 10 (5%) were reoperations, 115 (57%) had one or more myocardial infarction, 21 (10%) had diabetes. In total 733 anastomoses were constructed (3.7/patient), with sequential grafting in 124 (62%) patients. The clinical follow-up was complete. The patients were followed for up to 10 years (mean 6.4 ± 2.7 years).

RESULTS: Ten-year actuarial survival (including in-hospital death) was 87%. The actuarial freedom from angina pectoris, after hospital discharge, was 97% and 86% at 5 and 10 years respectively. None of the patients needed a repeat surgical revascularization after leaving the hospital, whereas 9 (5%) patients underwent a percutaneous transluminal coronary angioplasty. At 5 years 86% and at 10 years 69% of the patients remained free of any cardiac-related event.

CONCLUSIONS: The results of this study clearly indicate that the exclusive and extensive use of pedicled bilateral ITA and GEA in coronary bypass grafting provides excellent 10-year patient survival and functional improvement in terms of freedom from return of angina pectoris and, more impressive, freedom from any cardiac-related event. Our findings clearly corroborate the concomitant use of bilateral ITA and GEA grafts in selected patients with 3-vessel disease.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The superiority of the internal thoracic artery (ITA) for coronary bypass grafting compared with the saphenous vein grafts [1] has lead to a continuous effort of achieving a complete arterial myocardial revascularization. The use of ITA has resulted in decreased risk of death, reoperation, and angioplasty [2–5]. Other reports demonstrate excellent results with the use of bilateral ITAs especially when used as pedicled grafts [6]. This has encouraged surgeons to search for additional pedicled arterial conduits to achieve complete arterial myocardial revascularization. Pym, Suma, and Carter were the first who reported [7–9] the use of the right gastroepiploic artery (GEA) for coronary revascularization in 1987. Since then the GEA has gained worldwide popularity as the third pedicled arterial graft beside the ITAs [10–13].

To examine the results of complete arterial revascularization with three arterial grafts we report the long-term (up to 10 years) clinical follow-up of 201 patients who underwent myocardial revascularization with the exclusive use of both ITAs and the GEA as pedicled grafts.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patient population
From November 1992 to May 2002, 201 patients were operated in three different hospitals (Catharina Hospital Eindhoven, St Antonius Hospital Nieuwegein, Leiden University Medical Center) with the use of bilateral ITA and GEA as pedicled grafts by one surgeon (G.T.). There were 192 (95%) men and age averaged 53 ± 7 years (range 37 to 75 years). Preoperative characteristics are shown in Table 1. Patients with a body mass index of more than 25 were classified as obese.

There were a few absolute contraindications: severe chronic obstructive airway disease (forced respiratory volume in 1 second of less than 1.2 L), patients with cardiogenic shock, extreme chest deformities, or severe or poorly controlled insulin-dependent diabetes mellitus. Previous upper abdominal surgery was a relative contraindication. In case of major surgery as gastrointestinal resection, the GEA was not used but cholecystectomy was not considered a contraindication.

There was no policy to exclude patients with hypertension, peripheral vascular disease, carotid disease, or hypercholesterolemia. Extensive coronary artery disease, an urgent presentation, or the presence of left main coronary artery disease were not considered contraindications.

Operative technique
The operative technique regarding the harvesting, routing and treatment of the pedicled bilateral ITAs and GEA has been reported previously [14]. A total of 733 anastomoses were performed using 603 grafts, with a mean of 3.7 (range 3 to 6) anastomoses per patient. Table 2 shows the site of the anastomoses. A sequential left ITA graft was performed in 103 patients (93 with two distal anastomoses and 10 with three distal anastomoses). A sequential right ITA graft was used in 18 patients and a sequential GEA graft in 3 patients. The most common combination in graft placement of the three in situ arterial grafts was sequential grafting of the left ITA to the diagonals and left anterior descending artery, the right ITA to the branches of the circumflex artery through the transverse sinus, and the GEA to the right coronary artery and its branches. This combination was chosen in 156 patients (62%). The next most common combination was the right ITA to the left anterior descending artery routing it in front of the ascending aorta, the left ITA to the branches of circumflex artery and the GEA to the right coronary artery and its branches in 44 (22%) patients. When the diameter of the target coronary vessel was less than 1.25 mm sequential grafting was not considered useful. An endarterectomy was performed in 13 (6%) patients. Systemic hypothermia and intermittent cold crystalloid cardioplegia was used in 97 (48%) of the patients. Systemic normothermia and intermittent antegrade warm-blood cardioplegia was used in 104 (52%) patients. The duration of cardiopulmonary bypass averaged 104 min (range 64 to 160 min) and aortic cross-clamp time averaged 74 min (range 44 to 142 min).

Statistical analysis
The data are presented as frequency or mean ± SD. Characteristics of the patient group were compared by ² or Fisher's exact probability test. Long-term event-free and survival curves were estimated by the Kaplan-Meier method. At 10 years 17 patients remain under observation; therefore, unadjusted actuarial survival rates for 5 and 10 years are given. Rate of return of angina is expressed as a percentage of the hospital survivors.

To determine the effects of various predictors and operative methods univariate and multivariate Cox proportional hazards models were applied.

All analyses were performed using commercial statistical software (SPSS 11.0 software; SPSS, Inc, Chicago, IL).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Early results
Six patients (3%) died during their hospital stay, including 4 cardiac deaths and 2 noncardiac deaths (both multiorgan failures).

Postoperative low cardiac output syndrome needing a marked inotropic support (5 dopamine or dobutamine) occurred in 17 (8%) patients; 7 (3%) needed inotropic support for more than 24 hours. Insertion of an intraaortic balloon pump was required in 7(3%) patients. In 11 patients (6%) myocardial ischemia and hemodynamic deterioration persisted despite adequate drug treatment with afterload reducing drugs and antispasmodic agents. In these patients additional saphenous vein bypasses were constructed (one of them received a temporary LVAD). In 4 of the 11 patients additional grafts were placed on the anterior, lateral, and posterior wall, in 3 only on the anterior wall, and in 4 only on the inferior wall. Decision on where to put additional grafts was made on basis of ECG changes and regional wall motion disturbances documented with echocardiography. Perioperative myocardial infarction occurred in 10 (5%) patients, with hemodynamic deterioration in 4. In these 4 patients echocardiographic changes could be documented. Reoperation for postoperative bleeding was necessary in 8 (4%) patients, of which 2 had an intraabdominal bleeding. One patient had a tear in the spleen and required a splenectomy.

The other noncardiac perioperative complications included prolonged ( > 48 hours) ventilation in 7 (4%), mediastinitis in 3 (2%) (one of whom had diabetes), and cerebrovascular accident in 2 (1%) patients.

Follow-up
No patient was lost to follow-up (mean follow-up 6.4 ± 2.7 years). During follow-up 11 patients died, 3 from a cardiac cause. Noncardiac deaths were malignancy (n = 5), renal failure (n = 1), aortic rupture (n = 1), and a motor vehicle accident (n = 1). Kaplan-Meier curve for survival of all cause mortality is shown in Figure 1. Unadjusted actuarial survival rate at 5 years was 93% and at 10 years 87%.

View larger version (11K): [in this window] [in a new window]   Fig 1. Predictive survival after coronary bypass surgery with bilateral internal thoracic artery grafting and gastroepiploic artery (including hospital deaths).

View larger version (11K): [in this window] [in a new window]   Fig 2. Predicted freedom from angina after coronary bypass surgery with bilateral internal thoracic artery grafting and gastroepiploic artery grafting.

View larger version (11K): [in this window] [in a new window]   Fig 3. Predicted cardiac-related event-free survival (including in-hospital reinterventions, in-hospital infarction, and in-hospital mortality).

Six patients had return of angina at rest. These patients underwent angiography and a PTCA. Three patients underwent a PTCA of the right coronary artery, 2 with an occluded GEA and one with a slender sign of the GEA. One patient underwent a PTCA of the LAD for a nonfunctional LITA, one for an ungrafted diagonal branch and 1 for an ungrafted marginal branch. The ungrafted branches in which a PTCA was performed did not show a significant stenosis at time of operation.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Complete arterial revascularization has gained popularity in the past years. However in triple-vessel disease complete arterial revascularization using only ITA as pedicled grafts is not always possible. Attempts to provide complete arterial revascularization in three-vessel disease, beside bilateral ITA, have focused on the GEA. Angiographically and histologically, the GEA shows a very low frequency of arteriosclerosis [15]. The in situ pedicled GEA is long enough to reach any coronary artery [16], and harvesting takes no longer than harvesting the ITA. The mid term and late angiographic results of the GEA graft are satisfactory. Suma and coworkers reported a 10 years patency of 62.5% [17]. In a combined angiographic and Doppler study, the GEA showed an overall graft patency rate of 97% at mean follow-up of 4 months (range 2 to 17 months) [18]. Another characteristic of the GEA is its adaptability to improve its flow in response to augmented myocardium demand [19].

This study presents the longest follow-up reported on arterial revascularization with the use of exclusively three pedicled arterial grafts. The actuarial 7 year survival in our group was 91% which is comparable to the outcome of Bergsma [20] and Nishida [21] who also reported a 7-year survival of 91% and 88%, respectively, using both ITAs and the GEA.

The outcome is also comparable with other studies who reported their results using both ITAs and vein grafts or GEA and other grafts (see Table 4). The 92% angina pectoris free survival at 7 years is very satisfactory compared with other studies. This might be the result of the use of exclusively arterial grafts and the completeness of revascularization with a high mean number of anastomoses of 3.7 per patient.

After leaving the hospital none of the patients underwent a re-CABG and only 9 patients needed a PTCA during follow-up (3 of them for an ungrafted vessel).

The cumulative probability of event-free survival from myocardial infarction in our study was 91% at 7 years. In the calculation of the actuarial freedom from myocardial infarction we included 10 in-hospital infarctions. After discharge from hospital only 3 patients suffered a myocardial infarction. That underlines that, patients revascularized with both ITAs and GEA, have a very low probability of suffering from myocardial infarction in the follow-up period. This is comparable with other studies (Table 4). This report also confirms that reoperation, after the in-hospital period, is very exceptional with the use of exclusively pedicled arterial grafts.

Actuarial freedom from angina pectoris was 92% at 7 years, which is significantly better than in the studies in which both ITA and vein grafts were used and comparable with the studies in which also bilateral ITA and GEA were used (Table 4).

In the multivariate Cox proportional hazard analysis obesity was the independent predictor of long-term survival. Although cardiac operations in obese patients have been studied and are generally considered safe [23], Prabhakar and colleagues [24] demonstrated that extreme obesity (body mass index of 40 or more) is a significant independent predictor for adverse outcomes after coronary bypass operation. In our study diabetes was not an adverse predictor for long-term survival. This compares favorably with results reported by Lytle who showed that in diabetic patients survival is better when using bilateral ITA grafts [6]. Because in our group only arterial grafts were used, this could explain that diabetes was not an independent predictive factor of long-term survival. Moreover these results could be achieved without an increased morbidity most specially the risk of sternal wound complications. In our study, among the 3 patients with postoperative mediastinitis only 1 had diabetes.

Total arterial revascularization can be achieved with both ITA and GEA as pedicled grafts in every suitable patient using a sequential bypass technique. We prefer this technique instead using free arterial grafts such as the radial artery or composite ITA graft technique. There is no need for proximal anastomoses to the often diseases ascending aorta or to another in situ arterial grafts. With pedicled grafts we assure to the myocardium three different sources of blood supply, which is in the long-term the preferable technique.

In conclusion, the results of this study clearly indicate that the exclusive and extensive use of pedicled bilateral ITA and GEA grafts in coronary bypass grafting provides excellent 10-year patient survival and functional improvement in terms of freedom from return of angina pectoris and more impressive freedom from any cardiac-related event. Therefore, our findings clearly support the concomitant use of pedicled bilateral ITA and GEA grafts for myocardial revascularization in selected patients with three-vessel disease.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Abstract]
2. Endo M., Nishida H., Tomizawa Y., Kasanuki H. Benefit of bilateral over single internal mammary artery grafts for multiple coronary artery bypass grafting. Circulation 2001;104:2164-2170.[Abstract/Free Full Text]
3. Rizzoli G., Schiavon L., Bellini P. Does the use of bilateral internal mammary artery (IMA) grafts provide incremental benefit relative to the use of a single IMA graft? A meta-analysis approach. Eur J Cardiothorac Surg 2002;22:781-786.[Abstract/Free Full Text]
4. Taggart D.P., D'Amico R., Altman D.G. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001;358:870-875.[Medline]
5. Dion R., Etienne P.Y., Verhelst R., et al. Bilateral mammary grafting. Clinical, functional and angiographic assessment in 400 consecutive patients. Eur J Cardiothorac Surg 1993;7:287-293.[Abstract]
6. 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]
7. Pym J., Brown P.M., Charrette E.J., Parker J.O., West R.O. Gastroepiploic-coronary anastomosis. A viable alternative bypass graft. J Thorac Cardiovasc Surg 1987;94:256-259.[Abstract]
8. Suma H., Fukumoto H., Takeuchi A. Coronary artery bypass grafting by utilizing in situ right gastroepiploic artery: basic study and clinical application. Ann Thorac Surg 1987;44:394-397.[Abstract]
9. Carter M.J. The use of the right gastro-epiploic artery in coronary artery bypass grafting. Aust NZ J Surg 1987;57:317-321.[Medline]
10. Jegaden O., Eker A., Montagna P., et al. Technical aspects and late functional results of gastroepiploic bypass grafting (400 cases). Eur J Cardiothorac Surg 1995;9:575-580.[Abstract]
11. 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]
12. Suma H., Amano A., Horii T., Kigawa I., Fukuda S., Wanibuchi Y. Gastroepiploic artery graft in 400 patients. Eur J Cardiothorac Surg 1996;10:6-10.[Abstract]
13. Hirose H., Amano A., Takanashi S., Takahashi A. Coronary artery bypass grafting using the gastroepiploic artery in 1,000 patients. Ann Thorac Surg 2002;73:1371-1379.[Abstract/Free Full Text]
14. Tavilla G., Jackimovicz J., Berreklouw E. Intraoperative blood flow measurement of the right gastroepiploic artery using pulsed Doppler echocardiography. Ann Thorac Surg 1997;64:426-431.[Abstract/Free Full Text]
15. Larsen E., Johansen A., Andersen D. Gastric arteriosclerosis in elderly people. Scand J Gastroenterol 1969;4:387-389.[Medline]
16. Tavilla G., van Son J.A., Verhagen A.F., Smedts F. Retrogastric versus antegastric routing and histology of the right gastroepiploic artery. Ann Thorac Surg 1992;53:1057-1061.[Abstract]
17. Suma H., Isomura T., Horii T., Sato T. Late angiographic result of using the right gastroepiploic artery as a graft. J Thorac Cardiovasc Surg 2000;120:496-498.[Abstract/Free Full Text]
18. Tavilla G., Pijls N.H., Berreklouw E., Peels K.H. Noninvasive assessment of right gastroepiploic artery graft patency using transcutaneous color Doppler echocardiography. Ann Thorac Surg 1999;67:624-628.[Abstract/Free Full Text]
19. Tavilla G., Pijls N.H., Peels K.H., Berreklouw E. Noninvasive assessment of coronary flow reserve in the right gastroepiploic artery graft. Ann Thorac Surg 2000;70:2040-2044.[Abstract/Free Full Text]
20. 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 bypass graft surgery with bilateral internal thoracic and right gastroepiploic arteries. Circulation 1998;97:2402-2405.[Abstract/Free Full Text]
21. Nishida H., Tomizawa Y., Endo M., Koyanagi H., Kasanuki H. Coronary artery bypass with only in situ bilateral internal thoracic arteries and right gastroepiploic artery. Circulation 2001;104:76I-80.
22. Lytle B.W., Loop F.D. Superiority of bilateral internal thoracic artery grafting: it's been a long time comin'. Circulation 2001;104:2152-2154.[Free Full Text]
23. Moulton M.J., Creswell L.L., Mackey M.E., Cox J.L., Rosenbloom M. Obesity is not a risk factor for significant adverse outcomes after cardiac surgery. Circulation 1996;94:II87-92.
24. Prabhakar G., Haan C.K., Peterson E.D., Coombs L.P., Cruzzavala J.L., Murray G.F. The risks of moderate and extreme obesity for coronary artery bypass grafting outcomes: a study from the Society of Thoracic Surgeons' database. Ann Thorac Surg 2002;74:1125-1131.[Abstract/Free Full Text]
25. Fiore A.C., Naunheim K.S., Dean P., et al. Results of internal thoracic artery grafting over 15 years: single versus double grafts. Ann Thorac Surg 1990;49:202-209.[Abstract]
26. Pick A.W., Orszulak T.A., Anderson B.J., Schaff H.V. Single versus bilateral internal mammary artery grafts: 10-year outcome analysis. Ann Thorac Surg 1997;64:599-605.[Abstract/Free Full Text]
27. Farinas J.-M., Carrier M., Hebert Y., et al. Comparison of long-term clinical results of double versus single internal mammary artery bypass grafting. Ann Thorac Surg 1999;67:466-470.[Abstract/Free Full Text]
28. Dion R., Glineur D., Derouck D., et al. Long-term clinical, and angiographic follow-up of sequential internal thoracic artery grafting. Eur J Cardiothorac Surg 2000;17:407-414.[Abstract/Free Full Text]

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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): Giuseppe Tavilla Jerry Braun Robert A. E. Dion Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tavilla, G. Articles by Dion, R. A. E. Search for Related Content PubMed PubMed Citation Articles by Tavilla, G. Articles by Dion, R. A. E. Related Collections Coronary disease