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Interact CardioVasc Thorac Surg 2007;6:397-402. doi:10.1510/icvts.2007.155259 © 2007 European Association of Cardio-Thoracic Surgery
What is the patency of the gastroepiploic artery when used for coronary artery bypass grafting?
a Department of Cardiac Surgery, Policlinico Hospital, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy Received 28 February 2007; received in revised form 2 March 2007; accepted 5 March 2007
*Corresponding author. Tel.: +39-080-5592392; fax: +39-080-5595087.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was to investigate the patency of the gastroepiploic artery when used for coronary artery bypass grafting. Altogether 304 papers were found using the reported search, of which 15 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We concluded that the right gastroepiploic artery has been found to have a good short- and long-term patency when anastomosed to the right coronary artery. Long-term patency is 80–90% at 5 years and around 62% at 10 years. Abdominal complications are low but they do occur. Anastomoses of the gastroepiploic artery to the left anterior descending artery perform much more poorly and should be avoided if possible. The long-term patency of the gastroepiploic artery seems to be similar to that of the saphenous vein.
Key Words: Evidence-based medicine; Gastroepiploic artery; Thoracic surgery; Graft patency; Coronary artery bypass
A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
In [patients undergoing coronary artery grafting] does [gasteropiploic artery] have [good patency].
You are about to perform a coronary arterial bypass graft on a 47-year-old ex-smoker who has triple vessel disease requiring three grafts. You elect to use both mammary arteries, but he is a manual labourer with many scars and tattoos on both his arms, and Doppler ultrasound and Allen's testing of his radials show poor flow on both sides. You wonder whether selecting the gastroepiploic artery would give him better long-term patency then using a saphenous vein.
Medline 1950 to Jan 2007 using OVID interface. [CABG.mp OR exp Thoracic Surgery/OR Coronary art$ bypass.mp OR Cardiopulmonary bypass.mp OR exp Cardiovascular Surgical Procedures/OR exp Thoracic Surgical Procedures/OR exp Coronary Artery Bypass] AND [exp Gastroepiploic Artery/or gastroepiploic.mp] AND [exp Vascular Patency/or patency.mp OR exp Mortality/OR mortality.mp].
Using the reported search, 304 papers were identified from which 15 papers provided the best evidence to answer the question. These are summarised in Table 1.
Hirose et al. [9] documented their 10-year experience with the gastroepiploic artery in 1000 patients. The 3-year arterial graft patency rates were left internal mammary artery (LIMA) 98.8%, the right internal mammary artery (RIMA) 98.2%, the radial artery 91.3%, the gastroepiploic artery (GEA) 91.1%, and the saphenous vein 90.6%, respectively (P<0.001). The GEA graft patency rate was significantly inferior to that of the LIMA or the RIMA (P<0.0005), but it was not significantly different from that of the radial artery or the saphenous vein graft. There was no significant differences in GEA patency when analysed by distal coronary target. Santos et al. [3] randomly allocated 60 patients into two groups. After the LIMA was anastomosed to the LAD, the obtuse marginal graft was randomly allocated to either a radial artery or the right gastroepiploic artery. These conduits were proximally anastomosed to the LIMA. The patency rate was 96.5% (56/58) for LITA, 89.6% (26/29) for RA and 68.9% (20/29) for RGEA, with a statistically significant difference between RGEA and RA (P=0.025). The authors cautioned against further use of the right gastroepiploic artery. Hirose et al. [9] reported the use of 1020 gastroepiploic arteries to the right coronary artery. One-year angiographic patency was 96%, but at 5 years post-operatively this dropped to 86% which was inferior to the right internal mammary artery and equivalent to the saphenous vein. Voutilainen et al. [4] performed 5-year angiography in 31 patients who received RGEA. The 5-year patency of RGEA grafts was 82.1%. The 5-year patency of the RGEA graft was near that of the left internal thoracic artery, at 90.3%, and the right internal thoracic artery, at 94.4%; and superior to the 66.7% patency of venous grafts. Formica et al. [5] presented data on 271 patients who had RGEA and in a second publication 174 patients who had exclusive RGEA and BIMA [6]. There was a very low angiography rate but there were no abdominal complications, and 10-year survival was 70% in these patients. Also freedom from angina and cardiac events at 9 years was 70%. Dietl et al. [7] in 1995 presented their experience with 127 patients who received RGEA compared to 114 patients who received a RIMA to their right-sided vessel. They performed very few postoperative angiograms but clinically found a significantly higher rate of perioperative MI (5.3% vs. 0.8%) in the RIMA group. Also there was a higher rate of sternal infection in diabetics who received a RIMA compared to RGEA. There were also five reoperations in the RIMA group compared to none with RGEA. Takahashi et al. [8] published a paper in 2004 reporting 69 GEA anastomoses to the circumflex territory or LAD. However, they also reported angiographic results in 128 anastomoses to the RCA. The patency over 3 years to the LAD territory was only 58%, to the circumflex was 93% and to the RCA territory was 94%. In particular they had two sudden deaths at days 10 and 12 in two patients straining to perform a bowel movement and several cases of arterial spasm. They recommended that use of the GEA be confined to RCA and circumflex vessels. Albertini et al. [10] reported that the right gastroepiploic artery was used as an in situ graft in 303 cases (98.7%) and as a free graft in 4 (1.3%). Ninety-six patients underwent angiographic restudy at a mean of 12 months (range 8–88) postoperatively. Patency of the right gastroepiploic artery grafts was 91.8%. Jegaden et al. [11] reported their results of the GEA in 400 patients. Fifteen-day angiographic patency was 92% and 4-year survival was 97%. Suma et al. [12] reported their results of the GEA in 936 patients. Early patency was 97%, and this dropped to 80.5% at 5 years and 62.5% at 10 years. Kamiya et al. [14] reported the early results of 98 patients having off-pump CABG with a skeletonised GEA. Their early angiographic patency was 98%. Fukui et al. [15] also reported good short term patency with GEA used for off-pump CABG. Manapat et al. [16] found that in 307 patients the GEA and also the inferior epigastric artery had acceptable morbidity and angiographic patency (80% patency). Grandjean et al. [17] reported a patency of 95% for GEA, although they also reported an initial learning curve for this procedure during which they had only a 77% patency.
The right gastroepiploic artery has been found to have a good short- and long-term patency when anastomosed to the right coronary artery. Long-term patency is 80–90% at 5 years and around 62% at 10 years. Abdominal complications are low but do occur. Anastomoses of the gastroepiploic artery to the left anterior descending, however, perform much more poorly and should be avoided. The long-term patency of the gastroepiploic artery seems to be similar to that of the saphenous vein.
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Abstract
1. Introduction