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J Thorac Cardiovasc Surg 1998;116:528-529
© 1998 Mosby, Inc.

Brief Communications

Minimally invasive left anterior descending coronary artery bypass with right gastroepiploic artery graft

Toshiya Ohtsuka, MD, Munemoto Endoh, MD, Shinichi Takamoto, MD

Tokyo, Japan

From the Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan.

Received for publication April 21, 1998. Accepted for publication April 24, 1998. Address for reprints: Toshiya Ohtsuka, MD, Department of Cardiothoracic Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113, Japan.

In minimally invasive coronary artery bypass grafting (MICABG) to the left anterior descending artery (LAD), the left internal thoracic artery (LITA) cannot be used in some patients. LITAs have already been used in the most of the redo cases. The harvested LITA grafts may be short or may have insufficient flow for coronary anastomoses. In these circumstances, the right gastroepiploic artery (GEA) can be an alternative graft.

In this communication, we report our clinical experience with MICABG to the LAD with GEA grafts.

Patients

The GEAs were used for MICABG to the LAD in 5 patients. There were 4 redo cases. In 3 of them, the LITAs had already been used for grafting. In 1 redo case, the LITA was left, but the GEA was selected for anastomosis to the distal LAD. In 1 primary case, the LITA graft had unsatisfactory flow, and the GEA was used instead.

Operation and follow-up

A left small anterior thoracotomy was placed at the anterior fourth or fifth intercostal space, and the LAD was identified. A small median laparotomy was made underneath the xiphoid process, and the GEA was pedicled as far as the pylorus ring with an ultrasonic device, Harmonic Scalpel with LCS (Ethicon Endo-Surgery, Inc., Cincinnati, Ohio).Go 1 A small hole was created in the left hemidiaphragm, and the GEA pedicle was advanced to the heart through this hole, passing anterior to the stomach and the left hepatic lobe. Coronary anastomosis to the LAD was performed on the beating heart with a mechanical stabilizer.

In each case, angiography was carried out for the GEA 1 week after surgery, and a transcutaneous Doppler graft-flow velocity study was performed at the time of discharge. At the outpatient clinic, this Doppler study was performed 2 weeks after discharge and was repeated every 3 months.

Results

The mean total operation time and GEA harvest time were 145 ± 35 minutes and 16 ± 4 minutes, respectively. The branches from the GEA and its accompanying vein were divided with excellent hemostasis with only the Harmonic scalpel. Each GEA pedicle reached the mid-LAD or higher and had no tension after anastomosis (Fig. 1).



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  		Fig. 1. Intraoperative view of pedicled GEA (arrows). Anastomosis to the LAD (arrowhead) and intra-abdominal pathway overlying left hepatic lobe (*) can be seen via 5 cm–long anterior thoracotomy (right top) and 6 cm–long median laparotomy (left bottom). N, Left nipple.

 
There were no deaths, and all patients have been angina-free after surgery. Follow-up, ranging from 1 to 7 months, is complete in all patients. Postoperative angiography revealed a patent GEA graft in each case. It was possible to assess each GEA graft repeatedly by Doppler study at the subxiphoid, and this showed a biphasic flow velocity pattern with diastolic augmentation (Fig. 2).



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  		Fig. 2. Transcutaneous Doppler flow velocity study for GEA at subxiphoid performed 7 months after the operation, demonstrating biphasic pattern with diastolic augmentation (arrows).

 
Comments

The GEA has been used in conventional CABG.Go 2 In our experience with MICABG, the GEA-to-LAD bypass through the pregastric, prehepatic, and transdiaphragmatic route was feasible via a small thoracotomy and laparotomy with satisfactory results. The Harmonic scalpel facilitated the formation of a GEA pedicle and reduced the harvest time by eliminating tying maneuvers.

In MICABG, long-term graft patency is a controversial issue; therefore patients should be closely observed.Go Go 3,4 In the technique reported here, the GEA graft passed just beneath the abdominal wall overlying the left hepatic lobe, and a Doppler probe placed at the subxiphoid was able to detect the graft flow reliably and repeatedly. The diastolic flow through the graft to the LAD could also be detected with a Doppler stethoscope. A high-pitched, continuous diastolic sound in each graft was distinctly audible at the subxiphoid. This is not measurable, but it is the easiest and the least expensive method for checking the graft patency.

In conclusion, MICABG to the LAD is feasible with a GEA graft by the pregastric, prehepatic, and transdiaphragmatic route via a small thoracotomy and laparotomy, and Doppler study can be reached at the subxiphoid for follow-up of graft patency.

References

  1. Swanstrom LL, Pennings JL. Laparoscopic control of short gastric vessels. J Am Coll Surg 1995;181:347-51.[Medline]
  2. Suma H, Wanibuchi Y, Terada Y, Fukuda S, Terayama T, Furuta S. The right gastroepiploic artery graft: clinical and angiographic midterm results in 200 patients. J Thorac Cardiovasc Surg 1993;105:615-22.[Abstract]
  3. Calafiore AM, Angelini GD, Bergsland J, Salerno TA. Minimally invasive coronary artery grafting. Ann Thorac Surg 1996;62:1545-8.[Abstract/Free Full Text]
  4. Landreneau RJ, Mack MJ, Magovern JA, Acuff TA, Benckart DH, Sakert RN, et al. "Keyhole" coronary artery bypass surgery. Ann Surg 1996;224:453-62.[Medline]




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