From the Department of Cardio-thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
Address correspondence and reprint requests to Dr. G. Tavilla, Department of Cardio-thoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands; e-mail: email@example.com.
Background: Anastomosis of the right gastroepiploic artery to vessels of the inferior wall of the heart can be performed using a transabdominal approach without sternotomy and without cardiopulmonary bypass.
Methods: From July 1999 to December 2004, 18 patients presenting with only right coronary artery disease were operated on by the transabdominal approach using a pedicled right gastroepiploic artery graft. In 14 patients, it was a redo operation. In all redo patients, a patent graft to the anterior wall was present. Median EuroSCORE was 5 (range 1–13). The right descending posterior artery was grafted in 10 patients, the right coronary artery in 8 patients.
Results: There was no hospital mortality and no conversion to sternotomy. Hospital morbidity consisted only of a right pleural hemothorax and a superficial wound infection. No blood transfusion was necessary in 16 (89%) patients. Hospital stay averaged 6 days.
Follow-up is complete and averaged 2 years (range 0.5–5.5 years). There was no late mortality. Seventeen patients (94%) were asymptomatic. One patient who experienced return of angina 1 year after the procedure underwent a percutaneous transluminal coronary angioplasty of the right coronary artery. Thirteen patients underwent a stress test at median follow-up of 14 months without signs of myocardial ischemia.
Conclusions: Off-pump coronary bypass grafting using a right gastroepiploic artery by the transabdominal approach is a safe and effective procedure with a low hospital morbidity and excellent follow-up. In redo operations, this technique excludes the risk of damaging patent grafts to the left coronary system.
Re-operation for coronary artery bypass grafting (CABG) has become a routine surgical procedure in most cardiac centers. The patients presenting for a redo operation are predominantly those who received, at time of primary CABG, a left internal thoracic artery (LITA) to the anterior vessels (in most of the cases still patent) and a saphenous vein graft to the rest of the coronary system (mostly diseased or occluded). When, in redo cases, the right coronary artery (RCA) is the only vessel involved, the transabdominal approach, without a median sternotomy and without the use of cardiopulmonary bypass, is a useful technique to avoid the risk of damaging a patent graft placed during primary CABG. In this setting, the pedicled right gastroepiploic artery (GEA) graft is the ideal conduit, because it can easily reach the RCA and its branches. This technique can be applied for primary CABG needing only a RCA revascularization as well.
Between July 1999 and December 2004, 18 patients underwent a transabdominal off-pump coronary artery bypass grafting using a pedicled GEA. Mean age was 65 years (range 53–75 years). There were 16 men and 2 women. The mean EuroSCORE was 5 (range 1–13). Eight patients were at high risk (EuroSCORE ≥ 6). Thirteen patients underwent coronary artery bypass surgery for the second time, and for 1 patient it was the third time. Four patients underwent CABG for the first time (primary CABG). The need for all repeat CABG was due to an occlusion of a vein graft placed on the RCA or right descending posterior (RDP) during the first CABG. All redo patients had patent grafts to vessels of the anterior wall of the heart: 8 patients a left internal thoracic artery (LITA) to the left anterior descending artery (LAD), 3 patients a sequential LITA to diagonal branch and LAD, 1 patient a right internal thoracic artery (RITA) to LAD running anteriorly to the ascending aorta, 1 patient a vein graft to LAD, and 1 patient a sequential vein graft to diagonal branch and LAD. Of the 4 primary CABGs, 3 patients had a failed percutaneous transluminal coronary angioplasty (PTCA) and 1 patient had an occluded calcified RCA not suitable for PTCA (Table 1).
The patient is placed in standard supine position. A dry air warming system is placed around the patient to maintain a normal body temperature. An 8-cm to 10-cm median incision is made above the xiphoid. This incision is long enough to permit the excision of the xiphoid process, to enhance exposure of the inferior wall of the heart, and distally, to allow easy access to the upper abdomen for GEA takedown. A normal skin retractor is positioned to permit the excision of the xiphoid process. The area between pericardium and diaphragm is open, and a transverse incision is made at this level to expose the inferior wall of the heart. The distal part of the RCA and the RDP are identified to select the target coronary suitable for the anastomosis. In reoperations, dissection of adhesions is limited to just permit exposure of the target coronary artery, and the rest kept intact, as such adhesions act as stabilizers.
At this point, the peritoneum is opened, the stomach is gently pulled out of the abdomen, and dissection of the GEA is performed in a skeletonized way. In the first 12 patients, the GEA was skeletonized using hemoclips to divide its branches at the stomach and omentum. In the last 6 patients, we used ultrascission (Harmonic Scalpel, Ethicon, Johnson & Johnson, New Brunswick, NJ). After heparinization (1.5 mg/kg), the GEA is divided distally and 5 to 6 mL nitroprusside hydrochloride (20 mg diluted in 50 mL physiologic saline) is injected into the lumen to relieve spasm. A hemoclip is placed at the distal end of the GEA, and the graft is placed in warm gauze imbedded in dilute nitroprusside and placed back in the abdominal cavity with the stomach. This handling of the GEA allows the artery to vasodilate by both the pharmacologic effect of the nitroprusside and distension by its own blood pressure. The skin incision is just long enough to receive a normal sternal retractor.
A hole in the diaphragm is made to route the GEA intrapericardially. The site of the opening is chosen depending on the target anastomosis. The GEA is always routed antegastrically and in front of the liver. Once the GEA is intrapericardial, an Octopus suction stabilizer (Medtronic Inc., Minneapolis, MN) is fixed on the retractor, cranially, and the suction branches are placed as closed as possible near the target coronary artery. The suction device not only acts as a coronary stabilizer, but also pushes back and pulls up the inferior wall of the heart for a better surgical view. Exposure of the surgical field, especially in deep chests, can be improved by either suturing the diaphragm to the caudal end of the skin incision or by placing a deep abdominal retractor in the pericardium and pulling caudally the diaphragm, the liver, and the other abdominal organs.
An incision in the target coronary of approximately 4 mm is made and, whenever possible, an intracoronary shunt is placed (8 patients). The GEA-coronary anastomosis is made using a continuous 8/0 or 7/0 polypropylene suture. The anastomosis is started by suturing the dorsal (deep) side of the coronary artery while the graft and coronary artery are separated. When the anastomosis is completed, 1 cc fibrin glue (Tissucol, Baxter, and Deerfield, IL) can be injected around the anastomosis to avoid any torsion of the GEA graft. Heparin is antagonized with protamine (half of given heparin dose). A small pericardial tube is placed for drainage at the end of the procedure.
The GEA was anastomosed to the RDP in 10 patients and to the RCA in 8 patients. In 1 patient, an endarterectomy (TEA) of an RDP was necessary. In 1 patient, concomitant TEA of a carotid artery was performed.
There was no hospital mortality. Neither hemodynamic changes nor transient S-T segment changes on the electrocardiogram occurred during the operation. Mean operation time was 170 minutes, ranging from 120 to 220 minutes. Extubation time ranged from 0 to 24 hours, with an average of 6 hours. Two patients were extubated before leaving the operating theater. Average intensive care unit stay was 24 hours with a range between 18 and 70 hours. Average in-hospital stay was 6 days (range 4–15 days). No patients had an elevation of troponin I levels postoperatively. No blood transfusion was needed in 16 (89%) patients. Hospital morbidity included a pneumothorax requiring drainage 1 day postoperatively in 1 patient and a superficial wound infection not requiring surgical treatment in another patient.
All patients were followed up for an average of 2 years (range 0.5–5.5 years). There was no late mortality. At time of follow-up, all patients were asymptomatic. One patient experienced return of angina 1 year after the operation. Coronary angiography showed a “slender sign” of the GEA, and PTCA of the RCA was successfully performed. To the question “Is your quality of life improved, the same or worse?,” all patients answered that their quality of life was improved after CABG.
Thirteen patients (72%) underwent the maximal stress test at a mean interval of 1.5 ± 1.2 years. All exercise test results were negative without any signs of myocardial ischemia.
Repeat coronary revascularization remains an important cause of significant morbidity and mortality in patients with coronary artery disease.1,2 Single-vessel off-pump reoperative CABG can be performed safely with a lower operative morbidity and mortality than on-pump CABG.3 In reoperative CABG, repeat sternotomy in patients with a patent left internal thoracic artery graft may cause injury of the graft with very serious complications.4 When the target coronary is solely the RCA or the RDP, the GEA is the graft of choice because of its position close to the inferior wall of the heart.5 And its use in re-operative CABG on the beating heart is feasible.6,7 The transabdominal approach has the advantage of avoiding sternotomy and consequently avoiding the risk of damaging a patent graft placed during the first operation.7
Harvesting of the GEA is easily performed through this small incision, and the skeletonization of the artery makes the operation easier. Making the anastomosis in a deep and small space, the visibility is much better with only the nude artery instead with a GEA surrounded with a big pedicle. In our group of patients, 14 were reoperations, all of them with a patent graft to the vessels of the anterior wall of the heart. In such patients, the transabdominal approach is an adequate surgical technique because it avoids the use of cardiopulmonary bypass and, without sternotomy, avoids damage of a patent graft placed during the first operation. In some cases of primary CABG involving only the RCA, the transabdominal approach is also useful because if a sternotomy is needed for future cardiac operations, it can be safely performed. Our technique is easily reproducible because it requires no additional equipment. However, this approach may present difficulties in obese patients with large anterior-posterior diameter of the chest, in whom longer instruments (ie, forceps, knife, scissors, and needle holder) may be necessary.
All patients were asymptomatic at follow-up (1 patient underwent a postoperative PTCA of the RCA), showing that with a minimally invasive procedure, maximal benefit for those very high-risk patients can be achieved.
In conclusion, off-pump coronary bypass grafting using the right gastroepiploic artery by the transabdominal approach is a safe and effective procedure with a low hospital morbidity and excellent follow-up. In redo operations, this technique excludes the risk of damaging patent grafts to the left coronary system.
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3. Stamou SC, Pfister AJ, Dangas G, et al. Beating heart versus conventional single-vessel reoperative coronary artery bypass. Ann Thorac Surg. 2000;69:1383–1387.
4. Gillinov MA, Casselman FP, Lytle BW, et al. Injury to a patent left internal thoracic artery graft a coronary reoperation. Ann Thorac Surg. 1999;67:382–386.
5. Tavilla G, van Son, JAM, Verhagen AF, Smedts F. Retrogastric versus antegastric and histology of the right gastroepiploic artery. Ann Thorac Surg. 1992;53:1057–1061.
6. Tavilla G, Pijls NHJ. Right gastroepiploic artery for coronary bypass reoperation without cardiopulmonary bypass. J Cardiovasc Surg. 1997;38:77–80.
7. Takahashi K, Minakawa M, Kondo N, et al. Coronary artery bypass surgery by the transdiaphragmatic approach. Ann Thorac Surg. 2002;74:700–703.
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