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J Thorac Cardiovasc Surg 1995;110:1768-1770
© 1995 Mosby, Inc.

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ATHEROSCLEROTIC LESIONS OF THE GASTROEPIPLOIC ARTERY: ONE CASE REQUIRING POSTOPERATIVE DILATION AND SOME INTERESTING POSTMORTEM OBSERVATIONS

Zurich, Switzerland

Accepted for publication Feb. 17, 1995. Use of the right gastroepiploic artery (RGEA) for myocardial revascularization has regained general acceptance since it has been proved that arterial conduits usually are superior to venous bypass grafts. Furthermore, the RGEA can be extremely useful in coronary reoperations and after stripping of saphenous veins. ^1-3 Early and mid-term experience has been satisfactory, and postoperative angiographic results confirm the clinical findings. ^4-6 However, some areas associated with the RGEA remain only partially known, particularly the incidence and severity of atherosclerosis. Atherosclerosis seems not to be prevalent in this vessel. However, the RGEA can be affected either directly or as a consequence of atherosclerotic lesions (e.g., ulcerations, cholesterol deposits) that develop in the descending thoracic aorta and the celiac trunk.

Case report

A 63-year-old patient with New York Heart Association functional class III angina had severe coronary artery disease involving the three main branches. He underwent an uncomplicated myocardial revascularization with moderate hypothermic cardiopulmonary bypass and cold blood cardioplegic arrest. The left internal mammary artery (IMA) was grafted to the left anterior descending branch (LAD), the right IMA to the right coronary artery, and the RGEA was anastomosed to the circumflex branch. Venous grafts were not available in this patient.

The RGEA was harvested with the aid of a stapling device and 4-0 silk ligatures. After heparinization, the distal RGEA was divided and cannulated with a soft olive-tipped needle through which a diluted papaverine solution was flushed. Immediately before grafting, RGEA inflow was considered to be normal.

The postoperative course was uncomplicated and the patient was discharged on postoperative day 8. Unfortunately, stress-induced retrosternal pain developed 3 months after the operation. An exercise electrocardiogram demonstrated inferior ischemic changes and angiography showed a 50% to 75% stenosis in the proximal segment of the RGEA (Fig. 1). The stenotic lesion was considered to be amenable to percutaneous dilation. This treatment was successful, as assessed by an immediate angiographic result, disappearance of exercise-induced ischemia, and relief of pain. Two years after angioplasty, the patient is free of symptoms. Treatment consists of low-dose salicylic acid and nifedipine 20 mg daily.

View larger version (125K): [in this window] [in a new window]   Fig. 1. Postoperative angiogram of RGEA demonstrates early filling of circumflex branch and significant stenosis of RGEA in its proximal segment (white arrow).

This case and some interesting postmortem observations, to be reported in this article, should focus interest on an important aspect of RGEA, that is, the prevalence of atherosclerosic lesions. In their comprehensive article about this topic, Suma and Takamashi ⁷ concluded that significant luminal narrowing by atherosclerosis is uncommon. The need to dilate a genuine RGEA stenosis after coronary revascularization seems to be rare.

Recently, the incidence, severity, and extent of atherosclerotic changes in the RGEA were assessed in our institution by postmortem examination (37 patients, mean age 64 years) and were compared with the lesions found in the LAD in the same patients. ⁸ Tissue probes (three of the LAD and five of the RGEA at 3 to 5 cm intervals) were fixed in 4% formalin solution and embedded in paraffin. The exact extension of the lamina elastica interna and the surface of the intima were determined for each cross section with an automatic planimeter (Graphic Tablet 911/A, Hewlett-Packard Company, Andover, Mass.).

The majority of LAD stenoses were found in the proximal part of the vessel, whereas these lesions, when present, were distributed along the whole length of the RGEA. The incidence and degree of stenosis in the LAD and RGEA are compared in Fig. 2. Some stenotic lesions were present in all patients: 4 of 37 patients were found to have an RGEA stenosis of greater than 50%, but 27 of 37 patients had such lesions in the LAD. Surprisingly, there were additional unexpected findings: intimal thickening or up to 50% stenosis of the RGEA was seen in 33 of 37 patients, asymptomatic stenosis of the celiac trunk in 3 patients, and a severly diseased thoracic aorta (including ulcers, thrombi, and cholesterol wall deposits) in 12 of 37 patients. In 2 patients, the gastroduodenal artery was narrowed as a consequence of chronic peptic ulcer disease.

View larger version (30K): [in this window] [in a new window]   Fig. 2. Incidence and severity of RGEA and LAD lesions in 37 postmortem examinations. Note the high incidence of lesions of greater than 50% stenosis in RGEA. These changes were found to be independent to age of patient.

Studies of atherosclerosis of the IMA have demonstrated that the degree of atherosclerotic changes correlates well with the severity of coexistent peripheral vascular disease and hyperlipidemia or with age, hypertension, and vascular disease. ^9-11 These findings could not be confirmed in the present observation. In contrast to previous, more optimistic reports, we found comparable atherosclerosic lesions in the LAD and the RGEA in 1 of 10 patients. The RGEA seems to be affected significantly more often than the IMA. ¹² With increasing age, the development of atherosclerotic lesions seems to be accelerated in the RGEA more than in the LAD.

The prevalence of atherosclerosis in the RGEA should not preclude its use. However, because of the present article and several previous reports, caution is advised in patients older than 60 years who have diffuse coronary artery disease with extended peripheral lesions, in patients with hypertrophic myocardium, and in possible competitive flow situations. Preoperative assessment of the RGEA either by angiography or by size and flow measurements ¹³ is recommended, at least in high-risk procedures.

Footnotes

From the Clinic for Cardiovascular Surgery, ^a Departments of Cardiology ^b and Pathology, ^c University Hospital, Zurich, Switzerland.

J THORAC CARDIOVASC SURG 1995;110:1768-70

References

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2. Mills NL, Everson CT. Right gastroepiploic artery: a third arterial conduit for myocardial revascularization. Ann Thorac Surg 1989;47:706-11.[Abstract]
   
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6. Ishiki T, Yamaguchi T, Nakamura M. Postoperative angiographic evaluation of gastroepiploic artery grafts: technical considerations and short-term patency. Cathet Cardiovasc Diagn 1990;21:233-8.[Medline]
   
7. Suma H, Takamashi R. Atherosclerosis of the gastroepiploic and internal thoracic arteries. Ann Thorac Surg 1990;50:413-6.[Abstract]
   
8. Domeisen H, Schneider J. Ausmass der Atherosklerose der Art. Gastroepiploica dextra und der Koronararterien bei Patienten über 30 Jahren: eine Autopsie-Studie. Zürich, 1992.
   
9. Sons HJ, Godehardt E, Kunert J, Lösse B, Bircks W. Internal thoracic artery: prevalence of atherosclerotic changes. J THORAC CARDIOVASC SURG 1993;105:1192-6.
   
10. Kay HR, Korns ME, Flemma RJ, Tector AJ, Lepley D. Atherosclerosis of the internal mammary artery. Ann Thorac Surg 1976;21:504-7.[Abstract]
    
11. Sisto T, Isola J. Incidence of atherosclerosis in the internal mammary artery. Ann Thorac Surg 1989;47:884-6.[Abstract]
    
12. Jühlke M, von Segesser LK, Schneider J, Turina M, Heitz P. Ausmass der Arteriosklerose der Arteria mammaria interna und der Koronararterien bei Männern im Alter von 45 bis 75 Jahren. Schweiz Med Wochenschr 1989;119:1219-23.[Medline]
    
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