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J Thorac Cardiovasc Surg 1995;110:1568-1569
© 1995 Mosby, Inc.

LETTERS TO THE EDITOR

Vascular reactivity of the gastroepiploic artery graft

Department of Cardiovascular Surgery
Geisinger Medical Center
Danville, PA 17822-1343

To the Editor:

I read with great interest the article by He and Yang (J THORAC CARDIOVASC SURG1995;109:707-15), in which they compared the pharmacologic reactivity of arterial grafts taken from patients undergoing coronary artery bypass grafting. They used segments of three types of arterial grafts: gastroepiploic (GEA), internal thoracic (ITA), and inferior epigastric artery arteries. They also compared the reactivity of coronary arteries taken from explanted hearts.

Their study revealed that the GEA had the highest contractility to various vasoconstrictors. However, He and Yang did not specify which segment of the arteries was used. This is a very important consideration, because the contractility of arterial grafts usually increases toward the distal end. In a previous publication, He ¹ demonstrated that the contractility of the distal section of the ITA correlated inversely with its diameter; that is, the smaller the diameter, the greater the tendency for spasm. The implication is that the distal ITA, or its branches, should not be used for the anastomosis. A similar observation was made by Grandjean and associates, ² that the distal segment of the GEA graft is more reactive and should be trimmed off.

Early in my experience with the GEA graft in 1992, I used longer grafts, usually 15 cm or even longer. The lumen at the distal end averaged 1 to 1.5 mm, and the measured flows were poor, barely 40 to 60 ml/min. Tendency for spasm at the distal end was frequently observed, and the vessel was extremely friable. With more experience, I found that shorter grafts (approximately 12 cm in length) correlated with better flows (100 to 270 ml/min) and with a larger lumen for the anastomosis, usually 2 to 3 mm in internal diameter. These larger, more proximal segments of the GEA are easier to handle, less friable, and have minimal or no tendency for spasm.

Furthermore, in the past I used to introduce papaverine hydrochloride into the lumen of the GEA graft routinely, a practice that I seldom use now, because it is not necessary with arterial grafts that are larger in diameter and, consequently, less reactive.

These shorter GEA grafts usually reach the posterior descending coronary artery without tension, if placed behind the stomach. The retrogastric route has the additional advantage of protecting the GEA from injury during a future abdominal operation. ³

In summary, vascular reactivity of arterial grafts depends on which segment is used for the anastomosis. Likewise, the artery tested to vasoconstrictors in vitro may also have different reactivity, depending on which segment was used. Ideally, the distal segments should be discarded, to minimize the risk of vasospasm.

I would like to encourage Dr. He to compare the pharmacologic reactivity of different segments of the GEA, to confirm my clinical observations.

References

1. He GW. Contractility of the human internal mammary artery at the distal section increases toward the end: emphasis on not using the end of the internal mammary artery for grafting. J THORAC CARDIOVASC SURG 1993;106:406-11.
   
2. Grandjean JG, Boonstra PW, den Heyer P, Ebels T. Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients. J THORAC CARDIOVASC SURG 1994;107:1309-16.
   
3. Dietl CA, Deitrick JE, West JC, Pagana TJ. Laparotomy after using the gastroepiploic artery graft: retrogastric versus antegastric route. Ann Thorac Surg 1995;60:382-6.[Abstract/Free Full Text]
   

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This Article 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): Charles A. Dietl Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dietl, C. A. Search for Related Content PubMed PubMed Citation Articles by Dietl, C. A.