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Ann Thorac Surg 2005;80:124-130
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Flow Capacity of Gastroepiploic Artery Versus Vein Grafts for Intermediate Coronary Artery Stenosis

^a Department of Surgery II, Tokyo Medical University, Tokyo, Japan
^b Department of Cardiology, Nishi-Tokyo Central General Hospital, Tokyo, Japan
^c Department of Cardiovascular Surgery, Sanno Hospital, Tokyo, Japan

Accepted for publication February 1, 2005.

^_* Address reprint requests to Dr Shimizu, Tokyo Medical University, Department of Surgery II, Nishishinjuku 6-7-1, Shinjuku-ku, Tokyo, Japan (Email: tshimizu-cvs{at}umin.ac.jp).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: Native flow competition is a significant factor affecting bypass graft patency. The objective of this study was to compare the effect of competitive flow on conduit flow dynamics in the gastroepiploic artery (GEA) and the saphenous vein graft (SVG).

METHODS: In 51 patents, 23 GEAs (in-situ grafts) and 28 SVGs (aortocoronary grafts) were examined using a Doppler-tipped guidewire during coronary angiography after coronary artery bypass. Graft flow volume at rest and maximum graft flow volume during hyperemia were calculated from graft diameter and average peak velocity at rest and maximum average peak velocity induced by papaverine hydrochloride injection. Grafts were classified according to the grade of native coronary artery stenosis; group S (14 GEAs and 16 SVGs) displayed over 75% stenosis and group M (9 GEAs and 12 SVGs) exhibited over 50% up to 75% stenosis.

RESULTS: In group S, no difference in flow volume was apparent between the GEA and the SVG at rest (36± 17 vs 42 ± 16) and during hyperemia (78 ± 30 vs 88 ± 28). In group M, flow volume of the GEA was significantly lower than that of the SVG at rest (17 ± 11 vs 38 ± 12; p = 0.029) and during hyperemia (32 ± 19 vs 94 ± 46; p = 0.001).

CONCLUSIONS: These data suggest that in intermediate coronary stenosis, GEA flow is compromised by native flow competition, whereas the SVG flow dynamics is maintained. However, the GEA can provide comparable flow capacity to the SVG and will achieve good surgical results when target coronary artery selection is appropriate.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
The right gastroepiploic artery (GEA) has been playing an important role as an arterial conduit for coronary revascularization [1]. The early graft patency rate of the GEA is comparable with that of the internal thoracic artery (ITA) [2, 3], whereas the 10-year patency rate of the GEA is inferior to that of the ITA [4]. Flow competition between the GEA and the coronary artery could be one of the major factors affecting graft patency [5]. Voutilainen and colleagues [6] reported the patency rate of the GEA to be low when the recipient coronary artery showed proximal stenosis of as much as 70%, allowing substantial competitive flow. Suma and colleagues [4] recognized that anastomosis to a less critically stenosed coronary artery was one of the major causes of late graft occlusion. On the other hand, the relationship between saphenous vein graft (SVG) patency and native coronary artery stenosis has been controversial. Some investigators have suggested that the patency rate of the SVG is reduced when native coronary artery stenosis is moderate [7, 8]. Conversely, others have reported that native coronary stenosis does not reduce SVG patency [9, 10]. Moreover, the effect of flow competition on SVG flow is unknown.

The GEA generally provides adequate flow to the myocardium where the graft is placed [11], however, a small GEA used as a sequential graft may cause ischemia due to inadequate flow [12]. The GEA, as well as the ITA, is generally grafted as an in-situ graft (pedicle graft). It has been reported that flow capacity of the in-situ ITA is inferior to that of the aortocoronary SVG [13]. Therefore, supplemental vein grafting is occasionally effective for arterial graft hypoperfusion [14]. For these reasons, flow capacity of the GEA may be inferior to that of the SVG.

Differences in flow characteristics between the GEA and SVG are not fully understood. Louagie and colleagues [15] compared intraoperative flow volume and found no flow difference between the GEA and the SVG. Intraoperative graft flow dynamics measured just after implantation under general anesthesia or cardiopulmonary bypass do not always represent actual graft flow characteristics. Therefore, postoperative studies may enable more accurate examinations under more physiologic conditions. Moreover, few data exist to compare flow capacity of the GEA with that of the SVG, not only for intermediate coronary stenosis but also for critical coronary stenosis.

An intravascular Doppler-tipped guidewire, developed as a coronary angioplasty guidewire, has been used for analysis of phasic flow velocity of the ITA and the SVG during postoperative angiography [16]. Using this technique, phasic flow velocity can be accurately quantified in the grafts under various competitive flow conditions. The purpose of this study was to compare the GEA and the SVG in terms of flow capacity for severe and moderate coronary stenosis, using a Doppler guidewire after coronary artery bypass.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Study Patients
Between 1997 and 1999, 147 patients underwent coronary artery bypass in our institutes (Tokyo Medical University Hospital, Nishi-Tokyo Central General Hospital), and 93 patients who had previously undergone coronary artery bypass grafting were referred to our institutes for the evaluation of graft patency. Of these 240 patients, 155 underwent revascularization of the inferoposterior wall of the left ventricle using the GEA or the SVG (GEA, n = 69; SVG, n = 86). Of these 155 patients, 134 underwent postoperative angiography; however, 24 were excluded from the study for the following reasons: sequential bypass grafting (n = 20), low left ventricular systolic function (ejection fraction, < 40%, n = 3), and composite GEA graft with the radial artery (n = 1). Of the remaining 110 patients, 69 were enrolled and gave informed consent to participate in this study. Of the 69 enrolled patients, a further 18 were excluded for the following reasons: difficulty in introducing the guidewire to the GEA (n = 7) or the SVG (n = 3), GEA spasm (n = 1), GEA anastomotic stenosis (> 50%, n = 1), GEA graft occlusion (n = 1), regression of native coronary stenosis (50% stenosis or less, n = 1), vein graft disease (n = 4).

The final study group consisted of 51 asymptomatic patients who underwent postoperative angiographic follow-up at intervals ranging from 2 weeks to 8 years (mean, 1.6 years) after surgery. Patient age ranged from 47 to 81 years (mean, 62 years). Grafts in this study consisted of 23 GEAs and 28 SVGs anastomosed to the posterior descending branch of the right coronary artery, the atrioventricular branch (the left ventricular branch) of the right coronary artery, or the posterolateral branch of the left circumflex artery.

Surgical Technique
The GEA was palpated gently to evaluate its size and length, then divided using surgical clips or silk ties and taken as an in-situ graft (pedicle graft) with accompanying veins and surrounding fat tissue. The GEA harvesting was abandoned if the artery was too small for grafting (less than 2 mm in diameter or smaller than the target coronary diameter). The proximal dissection was terminated above the anterior surface of the head of the pancreas. The saphenous vein was taken form the lower leg and grafted as an aortocoronary bypass conduit. The vein was taken from the upper leg if the lower leg vein was too small. All patients underwent standard coronary artery bypass using cardiopulmonary bypass under cardioplegic cardiac arrest.

Flow Velocity Measurement at Rest and During Hyperemia
Coronary angiography was performed through the standard femoral approach. After GEA or SVG angiography, a 5-French or 6-French catheter was positioned in the origin of the GEA or the SVG. A 0.015-inch or 0.018-inch 12 mHz Doppler guidewire (Flowire, Jomed Inc, Rancho Cordova, CA) was connected to a velocity meter (FloMap, Jomed Inc), which was advanced through the catheter into the graft and introduced to the distal portion of the graft (Fig 1). Phasic flow velocity was recorded at rest, after which the maximum average peak velocity during hyperemia (induced by 10 mg of papaverine hydrochloride injected into the graft) was recorded. Graft diameter at the points of flow velocity measurement was determined by angiography with an automated edge-contour detection system (Cardio 500; Kontron Electronic AG, Eching, Germany). Total graft flow volume (Q; mL/min) and Diastoloc graft flow volume (Qd; mL/min) were calculated as previously reported [17, 18], using the formula Q = 3.14 x (D/2)² x APV/2 x 60, Qd = Q x DVi/(DVi + SVi), where D is the graft diameter in cm, APV is the average peak velocity in cm/sec, Dvi is the diastolic time velocity integral, and Svi is the systolic time velocity.

View larger version (66K): [in this window] [in a new window]   Fig 1. A Doppler guide wire placement was made by advancing it through the catheter into the graft and it was introduced to the distal portion of the graft (A) gastroepiploic artery and (B) saphenous vein graft. The arrow shows the tip of the wire.

Statistical Analysis
The unpaired t test was used to compare two groups and one-way analysis of variance was used to compare four groups for continuous data. A Scheffe test was performed on the results of analysis of variance that showed significant differences. The Mann-Whitney’s U test was used to compare two groups and the Kruskal-Wallis test was used to compare four groups for rank data. The ² test was used for nominal data. A p value of less than 0.05 was considered to indicate statistical significance.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Baseline Characteristics
Patients with GEA grafts were significantly younger than those with SVGs. No significant differences were observed in gender, body surface area, number of bypass grafts per patient, history of myocardial infarction, history of inferoposterior infarction, or coronary risk factors (Table 1). Patients with the SVG tended to demonstrate a longer duration between surgery and follow-up performed in this study (p = 0.037). Intraoperative graft flow volume measured with a transit time flow probe did not differ significantly between the GEA and the SVG.

Phasic Flow Velocity Pattern
Typical bi-phasic velocity spectra, representing coronary circulation, were observed in the SVG. Compared with the SVG, the transition between systole and diastole in velocity spectra was obscure in the GEA. Retrograde flow (flow reversal) during early systole in the GEA was noted in 8 patients in group M and 1 patient in group S. Retrograde flow decreased or disappeared, whereas antegrade flow increased during hyperemia (Figs 2, 3).

View larger version (143K): [in this window] [in a new window]   Fig 2. Flow velocity spectra of the gastroepiploic artery (GEA) versus the saphenous vein graft (SVG) in group S. (A) Baseline flow velocity spectra acquired at the distal portion of the GEA grafted to the posterior descending branch of the right coronary artery with 100% occlusion. (B) Flow velocity spectra during hyperemia at the same point as Figure 2A. (C) Baseline flow velocity spectra acquired at the distal portion of the SVG grafted to the posterolateral branch of the left circumflex artery with 100% occlusion. (D) Flow velocity spectra during hyperemia at the same point as Figure 2C.

View larger version (140K): [in this window] [in a new window]   Fig 3. Flow velocity spectra of the gastroepiploic artery (GEA) versus the saphenous vein graft (SVG) in group M. (A) Baseline flow velocity spectra acquired at the distal portion of the GEA grafted to the posterolateral branch of the left circumflex artery with 60% stenosis. A swinging flow pattern (systolic retrograde and diastolic antegrade flow) was observed. (B) Flow velocity spectra during hyperemia at the same point as Figure 3A. (C) Baseline flow velocity spectra acquired at the distal portion of the SVG grafted to the posterolateral branch of the left circumflex artery with 70% stenosis. (D) Flow velocity spectra during hyperemia at the same point as Figure 3C.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

On the other hand, flow velocity in the GEA to coronary arteries with moderate stenosis was as low as that of the SVG. As the diameter of the GEA is smaller than that of the SVG, its calculated flow volume was less than that of the SVG. This difference was obviously due to flow reduction caused by flow competition between the GEA and the native coronary artery, and was also demonstrated during hyperemia. This could be due to anatomical differences between the GEA and SVG. The aortocoronary SVG is under direct aortic root pressure, whereas the GEA is a branch of the gastro-duodenal artery, which in turn diverges from the common hepatic artery, and thus is the fourth branch of the abdominal aorta. As coronary blood supply is determined by a pressure gradient between the aorta and the left ventricle, the driving pressure of the GEA could be lower than that of the SVG. In contrast, the relationship between flow in the SVG and severity of native coronary stenosis was not significant. We presume that native coronary stenosis does not significantly reduce SVG patency; however, it is theoretically possible that native flow may affect SVG flow to some degree.

It has been reported that flow velocity reserve [20] and ratio of systolic and diastolic velocity [21] obtained with transcutaneous Doppler echocardiography are useful indices assessing anastomotic patency of the GEA. Although graft flow reserve for lower grade stenosis tended to be lower in the GEA than in the SVG, this difference did not reach statistical significance. This could be attributed to a small number of study patients; however, we speculate that flow competition does not necessarily reduce graft flow reserve. Graft flow reserve is determined by the balance between native flow and graft flow at baseline and during hyperemia. The diastolic-systolic velocity ratio of the GEA did not correlate with flow competition. This index is usually reduced when anastomotic stenosis is significant [22], but is not reduced in competitive flow and is even occasionally increased [23, 24] as long as the graft remains patent. These findings may help us to distinguish between flow competition and anastomotic stenosis as causes of flow reduction in bypass conduits.

Waveform characteristic differences were noted between the GEA and the SVG. Typical bi-phasic velocity spectra representing coronary circulation were observed in the SVG, whereas the transition between systole and diastole in velocity spectra was obscure in the GEA. Flow reversal in early systole, the so called "to and fro pattern" [24] or "swinging flow pattern" [23], was observed in the GEA to the coronary artery with moderate stenosis. The distance from the aortic root to the graft anastomosis causes a delay in the pressure wave of the graft, with the wave reaching the GEA after the coronary artery, which is much closer to the aorta. Elasticity or compliance of the conduits [25] may also influence waveform shape. During hyperemia, retrograde flow decreased, whereas antegrade flow increased in the GEA for moderate coronary artery stenosis. These flow dynamics are also seen in the ITA graft under flow competitive conditions [24]. As long as forward flow increases during exercise or hyperemia, functional or anatomical graft patency will be maintained; however the prognosis of the graft under oscillating shear stress may be limited [26].

Some of the limitations of this study have already been described previously [19, 23]. Briefly, percent diameter stenosis is not always the best predictor of significant hemodynamic changes. Our results only demonstrated the hemodynamic difference between the GEA and the SVG. To conclude which conduit should be used for lower grade coronary stenosis, long-term follow up studies are required comparing the GEA and the SVG with moderately stenotic coronary arteries in terms of graft patency. In addition, the postoperative study period was disregarded when assessing graft flow. It has been reported that ITA graft flow is restricted in the early postoperative period, but improves later in the postoperative course [27]. In the present study, the relationship between graft flow and interval from surgery was obscure, possibly due to the small number of subjects.

The GEA exhibits wide individual variation in its length and caliber, and a small GEA may not be feasible as a coronary artery bypass conduit. Therefore, in order to achieve better surgical results, it is mandatory to carry out sufficient proximal and distal dissection to provide enough length and adequate caliber of the distal end of the GEA. We recently harvested the skeletonized GEA using an ultrasonic scalpel [28]; however, we did not use this technique in the present study. This technique is useful in obtaining larger bypass conduits and in securing the availability of the GEA under spasm-free conditions.

The GEA gives an excellent clinical performance when implanted for severe coronary artery stenosis using an appropriate surgical technique. Moreover, this conduit is particularly feasible for revascularization of the inferoposterior wall and can thus easily be combined with left ITA grafting to the left anterior descending artery, because the GEA. Combined with the bilateral ITAs, the GEA can achieve multiple complete arterial grafting using three in situ arterial conduits. This must be associated with excellent long-term patency and surgical results [29]. Furthermore, it is more beneficial to use these in-situ arterial conduits in an off-pump coronary artery bypass [30]. This approach allows an absolute non-touch aortic technique, reducing risks of perioperative neurologic complications.

Considering the long-term graft patency of the GEA, we cannot advocate this conduit grafting for lower grade coronary stenosis. However, the authors do not necessarily mean to endorse the use of the SVG for intermediate coronary stenosis. Comprehensive decision-making is required to determine which conduit should be used for each target coronary artery, and the radial artery or the ITA must also be considered. Alternatively, in conjunction with cardiologists, another choice is to leave the intermediate stenotic lesion ungrafted and treat it medically or perform a hybrid procedure with percutaneous angioplasty if the lesion is suitable.

Conclusions
Compared with the SVG, GEA graft flow was compromised at rest and during hyperemia for lower grade coronary artery stenosis. These results suggest that flow competition is one of the most significant factors reducing GEA graft flow and patency, whereas this factor is less significant for the SVG. Therefore, although the GEA may not be feasible for intermediate coronary artery stenosis, the SVG could represent a viable option in this situation. On the other hand, the GEA can provide comparable flow capacity to the SVG and can achieve good surgical results when the target selection is appropriate.

	References

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