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Ann Thorac Surg 2004;77:2046-2050
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Skeletonization of gastroepiploic artery graft in off-pump coronary artery bypass grafting: early clinical and angiographic assessment

Hiroyuki Kamiya, MDa*, Go Watanabe, MDa, Hirofumi Takemura, MDa, Shigeyuki Tomita, MDa, Hiroshi Nagamine, MDa, Taro Kanamori, MDa

a Department of General and Cardiothoracic Surgery, Kanazawa University Hospital, Kanazawa, Japan

Accepted for publication October 24, 2003.

* Address reprint requests to Dr Kamiya, Department of General and Cardiothoracic Surgery, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa, Japan 920-8641
e-mail: hkamiya88{at}yahoo.co.jp


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: Recently skeletonization has been recognized as an alternative to pedicle harvesting of the internal thoracic artery as a technique that increases the length and caliber size of the graft compared with pedicled internal thoracic artery grafts; however, this is not yet popular for harvesting the gastroepiploic artery (GEA). We report here our experience of skeletonized GEA grafting in off-pump coronary artery bypass grafting with early clinical and angiographic results. The purpose of this study was to evaluate skeletonization of GEA grafting in off-pump coronary artery bypass grafting with a large patient volume.

METHODS: One hundred sixty-eight patients including 131 men and 37 women (mean age, 65 years; range, 45 to 87 years) underwent the skeletonized GEA grafting in off-pump coronary artery bypass grafting. These patients represent 41% (168 of 407 patients) of those who underwent off-pump coronary artery bypass grafting operations during the same period. We used the GEA graft of choice in patients with right coronary artery lesion. Skeletonization was performed in a unique manner we developed.

RESULTS: There were no in-hospital deaths among the study patients. One patient had a perioperative myocardial infarction, which was considered a result of vasospasm of the GEA graft. None of the other patients had severe morbidity. The patency rate of the skeletonized GEA graft was 98.1% (151 of 154 distal anastomoses).

CONCLUSIONS: This study suggests that skeletonization of the GEA graft can enlarge its caliber size and improve its flow capacity. In addition, the acceptable early clinical and angiographic outcome suggests that use of the skeletonized GEA graft in off-pump coronary artery bypass grafting surgery is safe and effective.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Increasingly, surgeons are using the gastroepiploic artery (GEA) as an additional conduit to internal thoracic artery (ITA) for myocardial revascularization with acceptable results [1–3]. However, there has been anxiety regarding flow capacity of the GEA graft, because the GEA branches off from a more distal portion of the aorta [4–6]. Some authors emphasized that the luminal diameter of the GEA when used as a graft should be sufficiently large enough to avoid flow competition between the native coronary artery and the GEA graft [5, 6].

Recently skeletonization has been recognized as an alternative to pedicle harvesting of the ITA as a technique that increases the length and caliber size of the graft compared with pedicled ITA grafts [7–10], and the technique has also been applied for the harvesting of the radial artery by some surgeons [11, 12]. This technique appeared to be suitable for harvesting of the GEA graft, increasing luminal caliber size and contradicting the fear of flow competition. However, there have been only a few reports regarding the skeletonization of the GEA graft [13–15].

In our institute, we began to harvest the GEA using the skeletonized technique in September 2000, and we have performed off-pump coronary artery bypass grafting (OPCAB) of choice from the same time. We report here our experience of skeletonized GEA grafting in OPCAB with early clinical and angiographic results. The purpose of this study was to evaluate the skeletonization of GEA grafting in OPCAB with a large patient volume.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
From September 2000, we gradually introduced the technique of skeletonization of the GEA, and from November 2001, because we were convinced by the favorable angiographic results that skeletonization is the best method for harvesting the GEA, we began to harvest the GEA solely by this technique. From September 2000 to April 2003, 228 patients underwent GEA grafting with OPCAB. These patients represent 60% (226 of 407) of those who underwent OPCAB operations during the same period. We used the GEA graft of choice in patients with right coronary artery lesion with more than 80% stenosis and those younger than 80 years of age. Patients who underwent skeletonized GEA grafting are categorized into group 1 (n = 168) and those who underwent pedicled GEA grafting into group 2 (n = 60). Patients who received vein grafting are excluded from this study. Patient characteristics are summarized in Table 1.


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  		Table 1. Patient Characteristics and Operative Dataa

 
Operations were performed through a median sternotomy incision in 166 patients in group 1 and 58 patients in group 2, and a subxiphoid incision in 2 patients each in both groups. The ITAs and the radial artery (RA) were harvested as a pedicle using conventional technique with a cautery. In group 2, the GEA was harvested as a wide pedicle using a cautery. In group 1, the GEA was harvested in a skeletonized manner. Before skeletonization, the GEA was harvested as a wide pedicle (Fig 1A) including artery, vein, and fat using the Harmonic scalpel with coagulating shears (Ethicon Endosurgery, Cincinnati, OH). After administration of 1.5 mg/kg heparin, the distal site of the GEA was cut, and the pedicled GEA was pulled out from intraabdominal space, which made further manipulation very easy. In both groups, a phosphodiesterase 3 inhibitor, olprinone hydrochloride (5 mg of olprinone in 100 mL of normal saline) was administrated into the GEA intraluminally. The pedicle of the GEA was drawn out and strained. The facies anterior of the pedicled GEA was cut open, and the body of the GEA was exposed (Fig 1B). The surrounding fat was aspirated to separate the GEA body from the accompanying veins using the tip of the Harmonic scalpel (Fig 1C). At that time, the scissors of the Harmonic scalpel were closed. Small branch arteries of the GEA became visibly clear, and these branches were nipped with the Harmonic scissors and cut off (Fig 1D). Skeletonization of the GEA was achieved by repeating the manipulations mentioned above. The GEA was usually narrow before skeletonization, but the size of the GEA was increased after skeletonization in most cases. Only the portions of the GEA with diameter larger than 2.0 mm were used, and the distal narrow parts were abandoned.



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  		Fig 1. (A) Before skeletonization, the gastroepiploic artery was harvested as a wide pedicle. (B) The facies anterior of the pedicled gastroepiploic artery was cut open, and the body of the gastroepiploic artery was exposed. (C) The surrounding fat was aspirated to separate the gastroepiploic artery body from the accompanying veins using the tip of the Harmonic scalpel. (D) Small branch arteries of the gastroepiploic artery became visibly clear, and these branches were nipped with the Harmonic scissors and cut off.

 
The pericardium was opened with an inverted T-shaped incision after the harvest of the arterial grafts. The right pleural space was opened to create a space for the vertically placed heart to minimize hemodynamic compromise. After evaluation of the coronary artery status, the composite grafts were made with 8-0 polypropylene running suture.

Two deep pericardial sutures were placed to facilitate pericardial retraction for cardiac elevation and exposure. The heart was stabilized with an Octopus 3 stabilizer (Medtronic Inc, Minneapolis, MN) or a Doughnut stabilizer (Fukuda Denshi, Tokyo, Japan). A coronary active perfusion system, which we developed, was used in all cases to maintain myocardial perfusion during anastomoses [16, 17]. The most critical vessel, the left anterior descending coronary artery in almost all patients, was revascularized first to provide a backup to other areas. The distal anastomoses were performed with 8-0 polypropylene running suture.

The left ITA was anastomosed to the left anterior descending coronary artery in all patients in group 1 and in 58 patients in group 2. If necessary, the Y composite graft technique with the ITA and the RA was adopted to anastomose to the diagonal branch. Coronary arteries on the inferior or posterolateral wall, including posterior descending, posterolateral, and obtuse marginal coronary arteries, were revascularized by the GEA graft (Fig 2) or the composite graft with the GEA and the RA. Proximal anastomosis on the ascending aorta was not performed in any patient. The average number of distal anastomoses per patient and from the GEA inlet and the distributions of distal target sites anastomosed by the GEA graft or the composite graft with the GEA and the RA are shown in Table 1.



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  		Fig 2. An example of the angiography of the skeletonized gastroepiploic artery graft. The gastroepiploic artery was clearly visible with a large diameter. (Right) A whole view of the gastroepiploic artery graft. (Left) An enlarged view of the anastomoses. (PD = posterodescending coronary artery; PL = posterolateral coronary artery.)

 
The necessity and significance of postoperative coronary angiography was explained to all patients, and angiography was performed if patients agreed. Postoperative angiography was performed approximately 2 weeks after the operation in 145 patients (64%).

Results were expressed as mean ± standard deviation. Statistical analysis was performed using Student's t test for continuous variables or {chi}2 tests (Fisher's exact tests if n < 5) for categorical variables. A p value less than 0.05 was considered significant. All statistical analyses were performed using SPSS 10.0 software (SPSS Japan Inc, Tokyo, Japan).


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
There were no in-hospital deaths among the study patients. One patient of group 1 had a perioperative myocardial infarction, which was considered the result of vasospasm of the GEA graft. None of the other patients had low cardiac output, perioperative myocardial infarction, newly developed cerebrovascular events, or sternal wound infection. Two patients in group 1 and 1 patient in group 2 needed reoperation for postoperative bleeding. Postoperative atrial fibrillation occurred in 20 patients (11%) in group 1 and 5 patients (8%) in group 2.

The results of postoperative angiography are shown in Table 2. In group 1, six graft failures were observed: two showed flow competition between the GEA and the native coronary artery; one showed 90% stenosis at the distal anastomosis site of the GEA graft, and the other showed graft occlusion at the anastomosis site between the GEA graft and the RA. In most cases in group 1, it was clearly visible that the GEA had a larger diameter (Fig 2). In group 2, seven graft failures were observed: four exhibited flow competition between the GEA graft and the native coronary artery, two showed diffuse string sign of the GEA graft, and one showed graft occlusion. The ITA grafts and other additional RA grafts were all patent; however, one case of string sign of the ITA graft was observed in group 1.


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  		Table 2. Results of Postoperative Angiography

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
In this series, the functional patency rate between the two groups was significantly different, although definitive patency rate of both groups did not differ. The present study demonstrates that the use of the skeletonized GEA graft in OPCAB surgery is safe and effective with acceptable early clinical and angiographic outcome.

In general, it is well known that skeletonization of the arterial graft increases the length of the graft and flow capacity, and facilitates handling of the graft [18–22]. This technique has been applied mainly to the ITA; however, some surgeons have recently adopted this skeletonization technique also for harvesting the RA [11, 12]. Amano and colleagues [12] applied the skeletonization technique using the ultrasonic scalpel for the RA in 131 patients with excellent results. They demonstrated that the stenosis-free RA graft patency rate in patients who received skeletonized and pedicled grafting were 96.5% and 84.9%, respectively (p < 0.005). They described in the report that graft spasm seldom occurred with skeletonization using the ultrasonic scalpel, and their favorable angiographic results may be attributed to the complete reversal of vasoconstriction by removing all surrounding tissue.

It is well known that the GEA is a muscular artery similar to the RA with a propensity to exhibit vasospasm when grafted [23]. Considering the fact that skeletonization using the ultrasonic scalpel for harvesting the RA can be performed without resulting in vessel injury or spasm [12], this technique appeared to be also suitable for harvesting of the GEA. Moreover, the GEA sometimes has insufficient caliber size and free flow. Thus we attempted skeletonization of the GEA because we considered that the advantages of skeletonization would be most conspicuous in the GEA. We have not yet adopted the skeletonization technique to the ITA or the RA graft simply because we have been satisfied with the quality of those pedicled grafts and have not felt the need for skeletonization.

Major concerns about GEA grafting in coronary artery bypass grafting are its flow capacity and the caliber size. Ochi and associates [6, 15] recommended that the GEA should have a large luminal diameter (2 to 3 mm) at its anastomotic point to generate adequate perfusion pressure to avoid flow competition between the GEA graft and the native coronary artery. In this series, the functional patency rate between the two groups was significantly different, although definitive patency rate of both groups did not differ. Flow competition or diffuse string sign of the GEA graft was observed in 2 of 105 patients (2%) in group 1 and 6 of 40 patients (15%) in group 2. In this series, we visually observed that the caliber size of the GEA was enlarged by skeletonization. We have not performed any quantitative evaluation regarding the caliber size or the flow capacity of the GEA graft because of technical difficulty and the cost consideration. However, our intraoperative visual observations and the results of this series suggest that the caliber size of the GEA graft can be enlarged by skeletonization, resulting in an increase of its flow capacity.

In conclusion, our experience suggests that skeletonization of the GEA graft can enlarge its caliber size and improve its flow capacity. Moreover, the acceptable early clinical and angiographic outcome suggests that the use of the skeletonized GEA graft in OPCAB surgery is safe and effective


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Pym J., Brown P., Pearson M., Parker J. Right gastroepiploic-to-coronary artery bypass: the first decade of use. Circulation 1995;92(Suppl 9):II-45-49.
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