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Eur J Cardiothorac Surg 2004;26:1141-1148
© 2004 Elsevier Science NL

Long-term follow-up of total arterial myocardial revascularization using exclusively pedicle bilateral internal thoracic artery and right gastroepiploic artery

Cardiac Surgery Clinic, Department of Surgical Science and Intensive Care, University of Milan-Bicocca, San Gerardo Hospital, Monza (Milan), Italy

Received 24 June 2004; received in revised form 16 August 2004; accepted 26 August 2004.

^* Corresponding author. Tel.: +39 039 233 2540; fax: +30 039 233 2488. (E-mail: francesco_formica{at}fastwebnet.it).

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
Objective: In order to reduce remote cardiac events associated with graft occlusions, arterial conduits are being increasingly utilized in coronary artery bypass grafting (CABG). While the internal thoracic artery (ITA) is the graft of choice for CABG, it is sometimes difficult or impossible to obtain a complete arterial revascularization only with ITAs in three-vessel diseases. We present our experience with total arterial myocardial revascularization with bilateral internal thoracic artery (BITA) and right gastroepiploic artery (rGEA). Methods: From April 1994 to January 2004, 174 patients (165 male, mean age 55.9±7.4) underwent coronary artery bypass procedure with exclusive use of BITA and rGEA. Left ventricular ejection fraction ranged from 20 to 68% (mean 55.9±6.8%). Seven patients (4%) had poor ejection fraction (<0.30), 23 (13, 2%) had acute myocardial infarction, 14 (8%) had left main disease. The mean CPB time was 96.9±15.7min and the mean cross clamping time was 70±14.2min. The mean number of distal anastomoses was 3.3±0.5 per patient. Results: Early mortality was 1.7%. The patients were followed for up to 9 years (mean follow-up time 6.3±2.6 years). Actuarial freedom from cardiac death (including hospital death) was 97.6%, at 9 years after the operation. Actuarial freedom from angina and cardiac events at 9 years was 79, 5% and 77, 6%, respectively. No perioperative myocardial infarction occurred. None of the patients needed a redo-CABG after leaving the hospital. Conclusions: This study indicates that the myocardial revascularization in young patients with three-vessel disease using exclusively pedicle BITA and rGEA provides excellent 9-year patient survival and improvement in terms of freedom from return of angina pectoris and freedom from any cardiac-related event. These results encourage the more extensive use of BITA and rGEA in selected patients with three-vessel coronary disease.

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
Long-term patency of internal thoracic artery (ITA) graft is superior to saphenous vein graft (SVG) and is leading to an increasing use of this arterial conduit and the benefit of left ITA graft rather than a SVG on left anterior descending artery is now demonstrated. Moreover, the vantage of two ITAs rather than one is widely described [1–3]; this explains the highest survival and lowest incidence of redo operation in patients previously underwent coronary artery bypass grafting (CABG) with double ITA compared with single ITA. This leads many cardiac surgeons to perform CABG operations with total arterial revascularization. However, both ITAs are often not enough for total arterial myocardial revascularization in three-vessel coronary artery disease [4–6]. Several reports have suggested the right gastroepiploic artery (rGEA) to be a promising arterial bypass conduit as an adjunct to the ITAs due to its equal size, free flow, length, comparable pharmacological responses and low susceptibility to atherosclerosis [7–9].

In this study we report our experience with the use of double ITAs and RGEA as pedicle arterial conduits for total arterial revascularization; we studied 174 patients by a postoperative clinical evaluation, in order to demonstrate that this surgical approach does not imply an increase perioperative and early postoperative complications and provide a satisfactory long-term follow-up.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
2.1. Patient demographics and selection
From April 1994 to January 2004, 2416 patients underwent isolated CABG. Among them, 370 patients (15.3%) with single vessel disease of left anterior descending disease, received one ITA graft, 374 (15.5%) with two-vessel disease received bilateral internal thoracic artery (BITA) grafts, either both pedicles or composite graft, 673 patients (27.8%) underwent CABG operation receiving one ITA and at least one saphenous vein graft (SVG), 694 (28.7%) received BITA and one or more SVGs, 267 patients (11%) had one or two ITAs with rGEA and a SVG. Among this latter group, 174 patients (7.2%), which forms the study group, received a total arterial myocardial revascularization with BITA and rGEA.

They were operated in two different hospitals (San Raffaele Hospital, Milan and San Gerardo Hospital, Monza) by one surgeon (G.P.). The mean age was 55.9±7.4 years (range 34–72 years). Preoperative patient characteristics are shown in Table 1.

Inclusion criteria were considered three-vessel disease in young patients with a life expectancy of 10 years or even more.

Preoperative exclusion criteria for rGEA harvesting were as follows: previous upper abdominal operation (excluding laparoscopic procedure), previous gastrectomy, active peptic ulcer, severe obesity, target coronary lesion below 90%, cardiogenic shock, severe chronic obstructive pulmonary disease (COPD), poorly controlled insulin-dependent diabetes mellitus.

2.2. Operative technique
A standard longitudinal sternal incision is used. The midline incision is prolonged to 5–8cm caudally along the linea alba. The peritoneum is opened. A very good exposure of the great gastric curvature is obtained by a small amount of air introduced into the stomach by a nasogastric tube. The size and pulsation of rGEA are verified by palpation along its whole course. Dissection of the rGEA with its pedicle begins in the middle of the greater curvature of the stomach, carried leftward to the splenic artery and stopped at two-thirds of the greater curvature; then the dissection is continued rightward to the origin of the rGEA from the gastro-duodenal artery and stopped at 2–3cm before the pylorus. The branches to the stomach and to the omentum are closed with staple gun (polisorb ligaclips) and divided by scissors. Care is taken to avoid twisting of the graft. The rGEA is divided after systemic heparinization. Papaverine was instilled intraluminally until 1999. Since 2000, a combined vasodilatator solution with glyceril-trinitrate and verapamil (GV solution) was used for avoiding vasospasm into the arterial lumen [10]. Subsequently, the rGEA pedicle is passed anterior or posterior to the stomach and then into the pericardial cavity through a 2-cm square window made in the diaphragm with electrocautery at the appropriate point. Standard CPB (mild systemic hypothermia 34–35°C), aortic cross-clamping, myocardial protection techniques according to Buckberg cardioplegic solution are used. Polypropylene 8-0 suture is used for continuous anastomoses and two additional sutures are used to tack the pedicle to the epicardium to avoid twisting. The bypass target of the rGEA was mainly the right coronary artery (RCA). If a long rGEA was available, the target was the circumflex branches.

2.3. Data collection and follow-up
By retrospective chart review, the following variables were collected: age, sex, preoperative angiography, cardiac profile, preoperative risk factors, graft material, surgical data, postoperative complication and mortality. The following major complications were studied: low-output syndrome, acute myocardial infarction (AMI), prolonged ventilation support, stroke, re-operations for bleeding, postoperative renal failure required haemodialysis, mediastinitis, and severe arrhythmia. The parameters studied over the period of follow-up are following:

(i) cardiac-related events which included new myocardial infarction, recurrence of angina, severe arrhythmia and congestive heart failure requiring hospitalization, redo-CABG, PTCA

(ii) death.

The end points were death, recurrence of angina and occurrence of cardiac-related events.

Follow-up data were collected by direct patient contact, or by mailed questionnaires, or by contact with the private cardiologist and compiled by February 2004.

2.4. Statistical analysis
The data are expressed as mean±standard deviation. Multivariate analysis was used to demonstrate independent predictive preoperative and operative risk factors affecting in-hospital mortality and occurrence of cardiac-related events. Multivariate Cox proportional-hazard models were applied to determine the effect of various predictors on cardiac death, on late survival, and on cardiac event-free survival. Hazard ratio (HR), 95% confidence intervals (CI) and levels of significance (P-value) were calculated. P-value <0.05 was considered to indicate statistical significance. Postoperative patient survival, angina-free rate and cardiac-related event-free rate were calculated using Kaplan–Meier method. All statistical analyses were performed using SPSS version 11.5 (SPSS Inc., Chicago, IL).

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
3.1. Operative results
Operative data are showed in Table 2. The total distal anastomoses were 576 with a mean number of distal anastomoses 3.3±0.5 per patient. The rGEA was anastomized to the right coronary system in 162 patients (93.6%) and to the left coronary system in 12 patients (6.8%); the rGEA was used as sequential graft in one patient on the right and left coronary system.

3.2. Hospital and late results
Three patients (1.7%) died in hospital of cardiac-related causes. No patient needed additional SVG in the site of rGEA graft or ITA graft. None underwent a second CABG operation during hospitalization due to rGEA graft failure. Postoperative low cardiac output syndrome, due to persisting myocardial ischemia, occurred in four patients (2.2%). These patients needed intraaortic balloon pump, despite inotropic support; all recovered subsequently. No gastrointestinal bleeding occurred. Postoperative complications are listed in Table 3.

View larger version (24K): [in this window] [in a new window]   Fig. 1. Survival curves according to Kaplan–Meyer method. (a) Freedom from total death. (b) Freedom from cardiac death including in-hospital death. (c) Freedom from recurrence of angina. (d) Freedom from cardiac-related event.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

The in situ pedicle rGEA is long enough to reach any coronary artery and its harvesting time is no longer than harvesting time of the ITA. Moreover, angiographically and histologically, the rGEA shows a very low frequency of arteriosclerosis and the mid-term and late angiographic results of the rGEA graft are very satisfactory when compared with vein grafts. In fact, as reported by Suma and co-workers, the patency rate at 10 years is of 62.5% [11]. In a recent report, Hirose [12] compared triple arterial CABG using two groups of patients: BITA plus rGEA vs. BITA plus RA. He could not describe any significant difference between the two groups, and the early angiographic results showed no rGEA graft occlusion with a stenosis-free anastomosis of 92.9%, and 1 RA graft occlusion with a stenosis-free anastomosis of 89.9%. In another recent study reported by Lev-Ran [13], two groups of patients, who received BITA plus SVG or BITA plus rGEA, were compared with the aim to draw the graft of choice to RCA. In this report the author did not find difference statistical significance between the two groups, in term of in-hospital mortality (rGEA 2.6% vs. SVG 3.9%), occurrence of postoperative complication and return of angina. Moreover, the author described 5 rGEA nonfunctioning grafts on 15 angiographic controls vs. no SVG graft occlusion on 11 angiographic controls, concluding that the use of rGEA to graft RCA did not confer clinical benefits over SVG graft on the same coronary system. This relative high rate of rGEA nonfunctioning grafts, could be caused by degree of proximal stenosis of the target coronary artery, which was equal to or more than 70%. As shown in some reports, the risk of competitive flow and of rGEA occlusion graft is high, if the stenosis of target coronary is less than 90% [11,14,15].

Moreover, an important characteristic of the rGEA is the adaptability to improve its flow in response to augmented metabolic myocardium demand as reported by Tavilla [16,17].

The actuarial 9-year survival in our group was 97.6%. The outcome is comparable with other studies who reported their results using both IMAs and rGEA. Bergsma [18] reported a 7-year survival of 91%, Nishida [19] described a 7-year survival of 88% and Tavilla [20] reported a 10-year survival of 87%. Moreover, the angina pectoris free survival at 5 and 9 years is 99.3 and 79.4%, respectively, and it is a very satisfactory outcome. Table 6 reports an analysis of risk factors of different population groups reported recently in literature, such as number of patients, age, EF<0.40, in-hospital mortality, number of anastomosis per patient, 7-year overall survival, 7-year freedom from angina, 7-year freedom from cardiac event, mean of follow-up. Actuarial 7-year survival of our study represents a satisfactory outcome compared also with studies in which single ITA, or double ITAs with vein graft are used, particularly considering that we included in-hospital mortality in the Kaplan–Meier method to calculate the actuarial 7-year survival (Table 6).

Since the beginning, we mostly used the in situ rGEA to graft the distal RCA, usually the posterior descending artery. Although Suma and colleagues reported that the rGEA can be used as a graft on the LAD, we have found no clinical benefit of rGEA-LAD bypass grafting except in special circumstances, such as a redo CABG where the IMA has been used previously [18]. In our group, the LAD is always revascularized with one of the IMAs. The target of rGEA is the RCA with severe (90%) or total proximal stenosis with good size peripherical vessels. Sequential grafting with the rGEA can be performed to the posterior descending artery and to the posterolateral branch of the circumflex artery.

Despite the remarkable clinical progress due to the use of arterial conduits in coronary surgery, some doubts have so far limited the extended use of rGEA. Some authors have recently pointed out the small diameter and postoperative vasospasm of rGEA. The rGEA has two important characteristics when compared with ITA. First, the high incidence of vasospasm during operation or postoperatively that justifies topical or intraluminal use of papaverin and systemic dose of calcium channel blockers. Second, the limited flow reserve of the rGEA due to its small diameter [14,23]. These two characteristics are implicated in the graft closure and ‘thinning down phenomenon’. Moreover, flow competition between the rGEA and native coronary artery has been discussed and the indication for using the rGEA remains controversial. Yasuura [23], in a mathematical model, suggests that the diameter of RCA and rGEA and the stenosis of RCA are determining factors of early or late graft occlusion. Actually, when the diameter of the rGEA is 0.5mm larger than RCA, the rGEA can be grafted even in a RCA with moderate stenosis. Case in which the diameter of rGEA is smaller than RCA and the pedicle is longer than 15cm, the rGEA flow could be drastically reduced. Therefore, to avoid spasm or graft closure, the diameter of rGEA should be large enough (more than 2.6mm) to perfuse adequately the entire vascular bed of the grafted coronary artery [24], above all in patients without infarct. Moreover, the rGEA pedicle should be short enough to reduce the resistance to blood flow through the arterial graft [23]. Our strategy to avoid perioperative vasospasm is based on three standpoints. First, the use of a short pedicle but long enough to reach the coronary target through the retrogastric course, which is the shortest route, utilizing in this way the segment of rGEA with larger diameter. Second, grafting only coronary arteries with suboccluded or even occluded lesion despite the absence or not of previous infarction in the corresponding area. Third, utilizing intraluminal vasodilators before performing anasthomosis. Since the beginning of our series until 1999, we have used papaverine solution either topically and intraluminally. From 2000 we have preferred to use the GV solution. We think this is an important tool for some reasons. It is not a acid solution due to NaHCO₃ which increases the pH from 4.8 to about 7.4 with very low risk of endothelial damage; its onset is more rapid than the papaverine due to glyceril trinitrate; a prolonged action is due to verapamil [10].We used the glyceril trinitrate–verapamil combination also for ITAs, radial artery and saphenous vein either topically and intraluminally.

The incidence of sternal dehiscence is very low (2.8%) and we did not find any correlation with diabetes. Actually, five patients experienced sternal dehiscence. Among them, nobody had diabetes, two patients had a previous CABG operation, and one was affected by COPD. Therefore, diabetes, regardless of severe uncontrolled forms, did not compromise the early recovery in our series.

4.1. Limitations of the present study
First, lack of angiographic controls of rGEA is one of limits of this study. A direct correlation between patency rate and clinical status and mortality is demonstrated, as reported by two large series of angiographic results, proposed separately by Suma [11] and Hirose [15]: the rGEA graft patency rates was 62.5% at 10 years and 84.4% at 5 years, respectively. Moreover, Hirose described a 5-year survival curve of 84.2% and event-free rates of 91.2% in the same interval time. Nowadays the need of surgeons to have an angiographic control of the patency of a graft conduit is highly important to manage coronary surgical disease and to act in the future. As a consequence of many angiographic controls, the long patency rate of ITAs and the low patency rate of SVG, are now well accepted. Angiographic controls of rGEA are less reported; nevertheless some papers describe satisfactory mid-term and long-term results with the use of rGEA without a large number of angiographic controls and only by the evidence of very low mortality and morbidity and by functional non-invasive cardiologic test [13,18,20]. Compared with other authors' series [11,15,20,23,24], we had satisfactory results at long-term follow-up; nevertheless we do not know if each rGEA graft in our group of patients is still patent or not. As long as a large series of angiographic controls will be performed, it is not possible to associate the low incidence of late cardiac events and cardiac deaths with the long patency of the rGEA graft, rather than to a wide net of collateral coronary flow. Moreover in our Country, as well as in most European Countries, the high cost of the catheter procedures, induces cardiologists to reduce postoperative coronary angiography. In this way postoperative catheterism rate is very low—compared with Japan, where a CABG patient is discharged usually after performing postoperative catheterism [6]. Least but not less important is the difficulty to obtain a consensus by asymptomatic patients to undergo a second angiographic control. This induces us to perform catheterism only in symptomatic patients.

Second, our group of patients has been compared with other historical control subjects. Furthermore, the follow-up we presented is still short if compared with the follow-up of the CABG series with BITA or single ITA and vein graft, so that at the moment it is impossible to draw more definitive conclusions.

4.2. Conclusion
In summary, the best way to avoid early and late graft failure in coronary surgery would be to minimize the use of venous conduits in favor of total arterial myocardial revascularization. The surgical strategy to obtain a total arterial revascularization with pedicle arterial conduits permits to use different blood flow supply and to get a no-touch aorta technique, very useful in patient with porcelain aorta. Low risk of redo operation is another important issue to consider above all when a young patient needs an extensive myocardial revascularization.

In our experience the extensive use of rGEA can be considered one of the best surgical alternative to SVGs in selected patients who are more likely to derive the highest benefits from the major durability of arterial grafts. The selection of patient is an important key concept. The rGEA could be considered the arterial graft of choice to revascularize the posterior wall of the heart in three-vessel disease when this arterial graft has a large internal diameter and when the RCA has a severe proximal stenosis or proximal occlusion with good run-off.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 

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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): Francesco Formica Pierpaolo Greco Antonello Martino Daniela Gastaldi Giovanni Paolini Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Formica, F. Articles by Paolini, G. Search for Related Content PubMed PubMed Citation Articles by Formica, F. Articles by Paolini, G. Related Collections Coronary disease