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Ann Thorac Surg 2007;83:2219-2220
© 2007 The Society of Thoracic Surgeons

Case Reports

Spontaneous Restoration of Patency in the Free Gastroepiploic Artery Graft: The Living Transplanted Vascular System for Coronary Revascularization

Tadahito Eda, MDa,*, Akio Matuura, MDa, Ken Miyahara, MDa, Haruki Takemura, MDa, Sadanari Sawaki, MDa, Teruaki Yoshioka, MDa, Naoki Yoshida, MDb

a Department of Cardiovascular Surgery, Aichi Prefectual Cardiovascular and Respiratory Center, Aichi, Japan
b Department of Cardiology, Aichi Prefectual Cardiovascular and Respiratory Center, Aichi, Japan

Accepted for publication December 15, 2006.

* Address correspondence to Dr Eda, 2135 Kariyasuka, Ichinomiya, Aichi, 491-0934, Japan (Email: cdb57810{at}hkg.odn.ne.jp).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
We report an incidence of coronary revascularization with the gastroepiploic artery in which angiography demonstrated patency at 1 month, severe narrowing at 1 year, and restoration of patency associated with progression of proximal coronary disease at 8 years. This report documents the reversibility of the free gastroepiploic artery.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
There are some reports that distal narrowing of the in situ left internal thoracic artery (LITA) graft, the so-called string sign on postoperative early angiography, disappears in the late phase [1–3]. In this report, we document the reversibility of the free gastroepiploic artery (GEA).

A 68-year-old man with normal left ventricular function and no history of diabetes or myocardial infarction underwent triple bypass grafting for worsening anginal symptoms caused by triple-vessel coronary disease. His preoperative coronary angiography was judged to show 75% stenosis in the left anterior descending artery (LAD) and left main trunks, 75% stenosis in the circumflex, 50% stenosis in the right coronary artery (RCA), and 50% stenosis in the 4 posterior descending artery (4PD).

The operation was performed with conventional cardioplegic arrest, and included left internal thoracic artery (LITA) grafting to the LAD, saphenous vein grafting to the obtuse marginal branch, and the free GEA grafting to the 4PD. The operative technique was described in our previous published study [4].

The patient’s postoperative course was uneventful. A routine coronary angiography at 1 month demonstrated that all grafts were widely patent; however, flow competition was seen between the free GEA and the native grafted coronary artery, which had 50% stenosis. A routine 1-year coronary angiography revealed a severe narrowing (string sign) of the free GEA. Stenosis of the RCA was 50%, the same as in the previous study (Fig 1). However, 8 years postoperatively, the free GEA string sign was not found, and its patency had markedly improved with the progression of the proximal disease in the native RCA from 50% to 90% (Fig 2).


Figure 1
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  		Fig 1. (A) Coronary angiography 1 month after surgery shows flow competition between the free gastroepiploic artery (GEA) graft and the native coronary artery. The widely patent free GEA graft was retrogradely filled from native right coronary artery. (B) Angiography of the free GEA graft 1 year after surgery shows a severe narrowing, the so-called string sign.

 

Figure 2
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  		Fig 2. (A) Coronary angiography 8 years after surgery shows progression of the stenosis in native grafted coronary artery. (B) Angiography of the free gastroepiploic artery (GEA) graft shows restoration of patency.

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
We have observed restoration of patency in transplanted free GEA, which was demonstrated to be patent 1 month after the operation, showed severe narrowing at 1 year, and became widely patent at 8 years when the RCA lesion progressed from 50% to 90%.

Dincer and Barner [3] reported that distal narrowing (string sign) of the in situ LITA graft on postoperative angiography disappears in the late phase. Here, we document similar restoration of patency in the free GEA.

For bypassing a coronary artery having less than critical stenosis, we prefer to use the GEA as a free graft instead of an in situ graft, because the free GEA graft in aortocoronary position provides more flow than the in situ GEA graft. But some reports warn of the risk of a free GEA spasm and a low patency rate [5]. To deal with this problem, we developed a special method for the free GEA grafting. The GEA graft was harvested en bloc with its satellite veins. The gastroepiploic vein was anastomosed to the right atrial appendage for venous drainage simultaneously with the GEA being grafted in the aortocoronary position. We previously reported that this method of free GEA grafting with venous drainage showed an excellent patency rate and immunity from vasospasm in the early and midterm angiographic results.

We consider that grafted free GEA in our method is not only an arterial conduit but also a part of the living vascular system transplanted in the aortocoronary position. The free GEA graft in our method may continuously maintain anatomic patency for a living organ, even under string sign condition. And the reduction in the lumen under these circumstances is a physiologic response resulting from reduced flow through the graft. The decrease in caliber may be necessary to maintain the velocity of flow and helps to ensure patency.

We here report the case of a grafted free GEA that showed severe thinning longitudinally, which subsequently regained wide patency in association with the progression of proximal disease in the grafted coronary artery. The reversibility of the graft suggests that the grafted GEA in our method is living and expresses good long-term performance.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Singh RN, Sosa JA. Internal mammary artery: a "live" conduit for coronary bypass J Thorac Cariovasc Surg 1984;87:936-938.[Abstract]
  2. Hata M, Shiono M, Orime Y, et al. Spontaneous recanalization of postoperative severe graft stenosisWhat is the cause and prognosis of the "string sign" in the internal thoracic artery?. Ann Thorac Cardiovasc Surg 1999;5:52-55.[Medline]
  3. Dincer B, Barner HB. The "occluded" internal mammary artery graft: restoration of patency after apparent occlusion associated with progression of coronary disease J Thorac Cariovasc Surg 1983;85381–20.
  4. Matsuura A, Yasuura K, Yoshida K, et al. Transplantation of the en bloc vascular system for coronary revascularization J Thorac Cariovasc Surg 2001;121:520-525.[Abstract/Free Full Text]
  5. Suma H, Wanibuchi Y, Terada Y, Fukuda S, Takayama T, Furuta S. The right gastroepiploic artery graft: clinical and angiographic midterm result in 200 patients J Thorac Cariovasc Surg 1993;105:615-623.[Abstract]



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