J Thorac Cardiovasc Surg 1994;108:590-592
© 1994 Mosby, Inc.
Use of the pedicled right gastroepiploic artery for coronary artery bypass grafting in the presence of calcified ascending aorta
Tadashi Isomura, MDa,
Kouichi Hisatomi, MDa,
Akio Hirano, MDa,
Ken-ichi Kosuga, MDa,
Kiroku Ohishi, MDa,
Masahiro Syukuwa, MDb,
Jun Fukui, MDb
Second Department of Surgery
Kurume University School of Medicinea
Medical Department
To the Editor:
Atherosclerotic disease in the ascending aorta can be one of the factors contributing to postoperative morbidity and mortality after coronary artery bypass grafting (CABG) as a result of manipulation, cannulation, or clamping of the aorta. As a treatment for this type of lesion associated with lesions of the internal thoracic artery (ITA), we describe a successful revascularization with the pedicled right gastroepiploic artery (GEA) in an empty beating heart.
A 62-year-old man was referred to our institution because of angina and dyspnea on exertion. He had a history of partial resection of the left upper pulmonary lobe and irradiation for pulmonary cancer when he was 57 years old. A coronary angiogram demonstrated a severe lesion in the left main coronary artery with a dominant left anterior descending branch (LAD) and a small circumflex branch (Fig. 1, A). No significant lesions were detected in the right coronary artery. The chest roentgenogram showed calcified lesions in the ascending aorta and aortic arch. The computed tomographic findings indicated extensive calcification of the ascending aorta, and a high-density lesion was seen around the left subclavicular artery, probably caused by adhesion and irradiation after the lung operation (Fig. 2, Aand B).
After median sternotomy, the GEA with its pedicle was dissected as described previously. 
1,2 Because palpitation showed the ascending aorta to be totally calcified, the left femoral artery was used for arterial cannulation. After the administration of heparin, the GEA was cut distally along approximately two thirds of the great gastric curvature, and 1 ml diluted papaverine hydrochloride (40 mg in 20 ml of normal saline solution) was injected intraluminally through the distal end with a diameter of 2.5 mm. After full flow of extracorporeal circulation (ECC) and mild hypothermia 34° C) had been obtained, the heart was vented from the right upper pulmonary vein to produce an empty beating heart. The GEA pedicle was passed into the pericardial cavity through a tunnel in the diaphragm. The LAD was then opened and a Flo-Rester coronary occluder (Bio-Vascular, Inc., St. Paul, Minn.) was put in place to block the coronary effluent and obtain a clear surgical field. The GEA was anastomosed to the LAD with a continuous suture of single 8-0 Prolene suture (Ethicon, Inc., Somerville, N.J.) in retrograde fashion (against the coronary flow). The time for completion of the anastomosis was 14 minutes and the patient was easily weaned from ECC for a total bypass time of 50 minutes. The postoperative course was uneventful without any need for homologous blood transfusion. A postoperative angiogram performed 2 weeks after the operation showed that at the site of the anastomosis the flow in the GEA filled the proximal and distal LAD (Fig. 1, B) with a flow competitive to that in the native LAD during the diastolic phase.
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Fig. 1. A,Preoperative angiogram demonstrates significant stenosisin the left main coronary artery (white arrow)with dominant LAD branch. B,Angiogram taken 2 weeks after operation demonstrates that the LAD was bypassed with the right GEA. The flow in the GEA filled the distal LAD, whereas it competed with the native coronary flow in the proximal site of anastomosis (arrow).
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Fig. 2. Preoperative computed tomographic findings indicate extensive calcification of the ascending aorta (A)and adherent lesion around the left subclavicular artery (B).
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Arterial grafts have been used as the first choice for CABG because of the good long-term patency. 3 The arterial graft, however, is also a useful conduit for CABG when the"aortic no-touch technique" 4 is used if the pedicle directly reaches the coronary artery. In our experience, the size of the GEA and the length of its pedicle are greater than those of the ITA, so that the pedicled GEA can reach not only the distal RCA but also the LAD or circumflex branch. 2 We used the pedicled GEA because the left ITA adhered to the surrounding tissue at the proximal site and the GEA seemed to match the large dominant LAD branch in size. Regarding the"no-touch aortic technique," CABG without ECC 5 or CABG by ventricular fibrillation with ECC 4 could have been performed, but we thought that CABG while the empty heart was beating during ECC could be performed safely and rather quickly weaned from ECC. We concluded that the pedicled GEA is an alternative graft for coronary revascularization in calcified lesions of the ascending aorta and, combined with the pedicled ITA, it can be useful to revascularize multivessel coronary lesions accompanying atherosclerosis of the aorta.
References
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Isomura T, Hisatomi K, Asoh K, et al. Revascularization with the right gastroepiploic artery in Kawasaki's disease [Letter]. J THORAC CARDIOVASC SURG 1990;100:796-8.[Medline]
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