• 
• 

Three Part Question

In [patients undergoing coronary artery grafting] does [gasteropiploic artery] have [good patency].

Clinical Scenario

You are about to perform a coronary arterial bypass graft on a 47-year-old ex-smoker who has triple vessel disease requiring three grafts. You elect to use both mammary arteries, but he is a manual labourer with many scars and tattoos on both his arms, and Doppler ultrasound and Allen's testing of his radials show poor flow on both sides. You wonder whether selecting the gastroepiploic artery would give him better long-term patency then using a saphenous vein.

Search Strategy

Medline 1950 to Jan 2007 using OVID interface.
[CABG.mp OR exp Thoracic Surgery/OR Coronary art$ bypass.mp OR Cardiopulmonary bypass.mp OR exp Cardiovascular Surgical Procedures/OR exp Thoracic Surgical Procedures/OR exp Coronary Artery Bypass] AND [exp Gastroepiploic Artery/or gastroepiploic.mp] AND [exp Vascular Patency/or patency.mp OR exp Mortality/OR mortality.mp].

Search Outcome

Using the reported search, 304 papers were identified from which 15 papers provided the best evidence to answer the question. These are summarised in Table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hirose et al, 2002, Japan	1000 consecutive patients having isolated CABG using GEA over 10 year period (1991-2001) . mean age 63.8 = 9.4 years ), male 767 The GEA was anastomosed to the right coronary artery in 87.8% and circumflex artery in 10.0%	Retrospective Cohort Study (level 2b)	Angiographic patency at 1, 3 and 5 years	GEA 1yr 98.7% 3yrs 91.2% 5yrs 84.4% LIMA 1 yr 99.6%, 3yrs 98.8%, 5yrs 97.0% P<0.0005	Angiography performed in 437 patient postoperatively and only on 221 patients after more than one year (mean interval 3.1+/- 1.8) Postoperative myocardial infarction with GEA failure occurred in 2 patients. There were 86 deaths. 36 cardiac related -cardiac events in 155 patients.
			Abdominal Complications	None
			Mortality	0.8% overall
Santos et al, 2002, Brazil	60 patients were randomly divided into two groups ('98-'99). First graft was always LIMA to LAD. 2nd graft randomized: group I received RGEA graft(n=32) group II, RA graft, (n=32) (both Y-grafted onto LIMA) The right coronary artery branches was grafted with saphenous vein graft (SVG) when necessary. All coronary arteries receiving arterial grafts had > or =75% proximal stenosis and diameter > or =1.5 mm.	PRCT (Level 1b)	Angiographic patency (8th to 15th postoperative day)	LIMA, 96.5% (56/58) Radial Artery 89.6% (26/29) GEA 68.9% (20/29) (P=0.025)	-short term follow up - Radial artery had better early results than right gastroepiploic artery Low numbers of patients patients were non-diabetic and young patients Note LIMA patency not affected by being used as inflow to GEA which was Y-grafted.
			Mortality	1 in each group ( non cardiac)
Voutilainen et al, 1996, Finland	31 consecutive patients having CABG using the RGEA from March 1987 to May 1990. Internal thoracic artery grafts were used concomitantly in all patients. Age group 55.1+/- 9.04. All patients received angiography at 3mths and 5 yrs	Prospective Cohort Study (level 2b)	5 year angiographic patency	RGEA 5yr patency 82.1% (23/28)LIMA 5yr patency 90.3% (95%CI 74.2-98.0) RIMA 5yr patency 94.4% (95% CI 81.3-99.3) Vein graft 5yr patency 66.7% (95%CI 38.4-88.2)	- small number of patients - young patients 3 month data not fully documented.
			Mortality / morbidity	One patient died. One had a gastric ulcer perforation 7 days post-operatively
			3 month angiographic patency	RGEA 80% (24 of 30)
Formica et al, 2006, Italy	271 patients undergoing CABG using RGEA (1995-2001) (257 males, mean age 56.2 +/- 7.1) Follow up 8.2 years	Retrospective Cohort Study, (level 2b)	Long Term Survival	10-year-survival 70.8%+/- 9.9%.	-Angiography was performed only on those patients with recurrent angina.
			Mortality / morbidity	Early mortality was 2.6% and postoperative MI occurred in three patients. There were 21 late deaths (3 cardiac)
			Abdominal Complications	No abdominal complications occurred during or after rGEA harvesting.
Formica et al, 2004, Italy	174 patients undergoing CABG using only BIMA and RGEA. (1994-2004) (165 male, mean age 55.9+/-7.4) The patients were followed for up to 9 years (mean follow-up time 6.3+/-2.6 years)	Retrospective Cohort Study (level 2b)	Freedom from angina or cardiac events at 9 years	Angina 79.5% Freedom from cardiac events 77, 6%	Results encourage the more extensive use of BITA and rGEA in selected patients with three-vessel coronary disease
			Mortality	Operative mortality 1.7% Actuarial freedom from cardiac death (including hospital death) was 97.6%, at 9 years after the operation
Dietl et al, 1995, USA	241 patients undergoing CABG from 1991-1994 with either RIMA or RGEA. RIMA 114 patients RGEA 127 patients	Prospective Cohort Study (level 2b )	Perioperative MI	RIMA 5.3%, ( 6 of 114), RGEA 0.8%, ( 1 of 127); P<.05	Authors suggest that the RGEA is particularly useful for diabetic as the sternal infection rate was significantly higher in the RIMA group.
			Mortality	RIMA 2.6% (3/114), RGEA 3.9% (5/127), P=NS
			Reoperation for graft failure	RIMA 4.4%, 5 of 114, RGEA 0%; P<.05
Takahashi et al, 2004, Japan	69 patients undergoing CABG to a left sided coronary artery during CABG from 1989-2000 by a single surgeon. 17 cases of GEA-LAD, 8 cases of GEA-LAD diagonal branch (Dx), 3 cases of GEA-RCA-LAD, 14 cases of GEA-circumflex artery (Cx), 4 cases of GEA-Cx-Cx, 23 cases GEA-RCA-Cx. Angiography in 49 cases 112 GEA anastomoses to the RCA also mentioned	Retrospective Cohort Study (level 2b )	Short term patency	GEA-LAD 96.0% (24 of 25) GEA-Cx 100% (18 of 18) GEA to RCA 98.1% (155/158)	The mid-term patency rate was poor for cases in which the gastroepiploic artery had been anastomosed to the left anterior descending coronary artery, which suggests that the procedure should be avoided. On the other hand, the patency rate was relatively favorable when the gastroepiploic artery had been anastomosed to the circumflex artery. Arterial spasm was major problem.
			>3 year patency	GEA-LAD 58.8% (10 of 17) GEA-Cx 93.3% (14 of 15) GEA-RCA 93.8% (120/128)
			Complications	2 patients suffered a sudden death during a bowel movement in hospital.
Hirose et al, 2004, Japan	1020 consecutive patients underwent CABG to the distal coronary artery using in situ GEA graft. -follow-up data were retrospectively analyzed 788 male and 232 female with a mean age of 63.6 +/- 9.7 37% of all patients receiving grafts at this hospital had a GEA graft. 482 patients received angiography at 1 year	Retrospective Cohort study (level 2b )	1 year patency	GEA 96%	The perioperative and clinical remote results of GEA grafting were satisfactory. The 5 year angiographic patency rates of GEA to the distal RCA was similar to the saphenous vein graft in this study. Angiographic follow up was biased towards patients with angina at 3 and 5 years.
			3 year patency	GEA 92% RIMA 93% Radial 93%
			5 year patency	GEA 86% RIMA 93% Saphenous vein 79.5%
			Operative mortality	0.6% (6 /1020)
Albertini et al, 1998, Belgium	307 patients undergoing CABG with GEA mostly to RCA (280) Their average age was 56.5 years (range 25-75) and 274 patients (89%) were male.	Cohort study (level 2b )	Symptomatic relief at mean 22 months	89% angina free	This study confirms that the right gastroepiploic artery can be used as a conduit for coronary artery bypass surgery with minimal mortality or morbidity. Mid-term patency rates and clinical outcome are encouraging
			12 month patency on angiography (96 patients)	GEA 91.8%
			Perioperative mortality	In-hospital mortality was 1.6% (five patients).
			Complications	Eleven (3.2%) right gastroepiploic artery grafts were doubled with saphenous vein intraoperatively because of persistent myocardial ischemia. There have been five late deaths (1.6%). A total of 265 (89.2%) patients are angina free
Jegaden et al, 1995, France	400 patients underwent CABG using the GEA to the RCA between 1990 and 994, (mean age 59 +/- 9 years)		Angiography at 15 days	GEA 92% ( 3 occlusions, 5 stenoses)
			Survival at 4 yrs	96.7%
			Perioperative Mortality	1.7%
Suma et al, 2000, Japan	936 patients undergoing CABG with RGEA between 1986 and 1999. Angiographic patency was studied in 685 patients within a year, 102 at 5 yrs and 52 over 5 yrs.	Retrospective Cohort study (level 2b )	Angiographic patency at 1 year	GEA 91.4%	Selection for angiography was biased towards patients with angina at 5-10 years.
			Angiographic patency at 5 yrs	GEA 80.5%
			Angiographic patency at 5-10 yrs	GEA 62.5%
Kamiya et al, 2004, Japan	98 patients undergoing off pump CABG with skeletonized GEA from 2000 to April 2003, 98 patients underwent total arterial revascularization with the skeletonized gastroepiploic artery	Prospective cohort study (Level 2b )	Early angiographic patency	98.%(118/120 anastomoses)	Short term follow up only
Fukui et al, 2005, Japan	107 patients undergoing off pump CABG using total arterial grafting. 69 had GEA. 97 angiograms	Cohort study (level 2b)	Early angiographic patency	LIMA 100% Radial Artery 97.3%	Short term patency only
Manapat et al, 1994, USA	290 patients who underwent CABG, including 152 patients who had Right GEA and 130 who had the inferior epigastric artery (IEA)	Cohort study (level 2b)	Hospital Mortality	GEA group 4% IEA group 0.8%	Short term follow up and only a small number of angiograms
			Complications	2 GI bleeds 1 episode of pancreatitis 1 IEA patient had abdominal wall bleed.
			Short term Angiographic patency	GEA 80% IEA 85.7%
Grandjean et al, 1994, Holland	300 patients undergoing CABG with GEA from 1989 to 1992.		Follow ( Mean 39 months )	95 % patency of GEA towards the end of the study. 77% patency at the beginning of the study	Poor initial patency was presumed to be related to a learning curve
			Hospital mortality	3.3% ( 10 patients )

Comment(s)

Hirose et al. documented their 10-year experience with the gastroepiploic artery in 1000 patients. The 3-year arterial graft patency rates were left internal mammary artery (LIMA) 98.8%, the right internal mammary artery (RIMA) 98.2%, the radial artery 91.3%, the gastroepiploic artery (GEA) 91.1%, and the saphenous vein 90.6%, respectively (P<0.001). The GEA graft patency rate was significantly inferior to that of the LIMA or the RIMA (P<0.0005), but it was not significantly different from that of the radial artery or the saphenous vein graft. There was no significant differences in GEA patency when analysed by distal coronary target. Santos et al. randomly allocated 60 patients into two groups. After the LIMA was anastomosed to the LAD, the obtuse marginal graft was randomly allocated to either a radial artery or the right gastroepiploic artery. These conduits were proximally anastomosed to the LIMA. The patency rate was 96.5% (56/58) for LITA, 89.6% (26/29) for RA and 68.9% (20/29) for RGEA, with a statistically significant difference between RGEA and RA (P=0.025). The authors cautioned against further use of the right gastroepiploic artery. Hirose et al. reported the use of 1020 gastroepiploic arteries to the right coronary artery. One-year angiographic patency was 96%, but at 5 years post-operatively this dropped to 86% which was inferior to the right internal mammary artery and equivalent to the saphenous vein. Voutilainen et al. performed 5-year angiography in 31 patients who received RGEA. The 5-year patency of RGEA grafts was 82.1%. The 5-year patency of the RGEA graft was near that of the left internal thoracic artery, at 90.3%, and the right internal thoracic artery, at 94.4%; and superior to the 66.7% patency of venous grafts. Formica et al. presented data on 271 patients who had RGEA and in a second publication 174 patients who had exclusive RGEA and BIMA. There was a very low angiography rate but there were no abdominal complications, and 10-year survival was 70% in these patients. Also freedom from angina and cardiac events at 9 years was 70%. Dietl et al. in 1995 presented their experience with 127 patients who received RGEA compared to 114 patients who received a RIMA to their right-sided vessel. They performed very few postoperative angiograms but clinically found a significantly higher rate of perioperative MI (5.3% vs. 0.8%) in the RIMA group. Also there was a higher rate of sternal infection in diabetics who received a RIMA compared to RGEA. There were also five reoperations in the RIMA group compared to none with RGEA. Takahashi et al. published a paper in 2004 reporting 69 GEA anastomoses to the circumflex territory or LAD. However, they also reported angiographic results in 128 anastomoses to the RCA. The patency over 3 years to the LAD territory was only 58%, to the circumflex was 93% and to the RCA territory was 94%. In particular they had two sudden deaths at days 10 and 12 in two patients straining to perform a bowel movement and several cases of arterial spasm. They recommended that use of the GEA be confined to RCA and circumflex vessels. Albertini et al. reported that the right gastroepiploic artery was used as an in situ graft in 303 cases (98.7%) and as a free graft in 4 (1.3%). Ninety-six patients underwent angiographic restudy at a mean of 12 months (range 8–88) postoperatively. Patency of the right gastroepiploic artery grafts was 91.8%. Jegaden et al. reported their results of the GEA in 400 patients. Fifteen-day angiographic patency was 92% and 4-year survival was 97%. Suma et al. reported their results of the GEA in 936 patients. Early patency was 97%, and this dropped to 80.5% at 5 years and 62.5% at 10 years. Kamiya et al. reported the early results of 98 patients having off-pump CABG with a skeletonised GEA. Their early angiographic patency was 98%. Fukui et al. also reported good short term patency with GEA used for off-pump CABG. Manapat et al. found that in 307 patients the GEA and also the inferior epigastric artery had acceptable morbidity and angiographic patency (80% patency). Grandjean et al. reported a patency of 95% for GEA, although they also reported an initial learning curve for this procedure during which they had only a 77% patency.

Clinical Bottom Line

The right gastroepiploic artery has been found to have a good short- and long-term patency when anastomosed to the right coronary artery. Long-term patency is 80–90% at 5 years and around 62% at 10 years. Abdominal complications are low but do occur. Anastomoses of the gastroepiploic artery to the left anterior descending, however, perform much more poorly and should be avoided. The long-term patency of the gastroepiploic artery seems to be similar to that of the saphenous vein.

References

1. Hirose H, Amano A, Takanashi S, Takahashi A. Coronary artery bypass grafting using the gastroepiploic artery in 1,000 patients. [see comment]. Ann Thorac Surg 2002; 73:1371–1379.
2. Santos GG, Stolf NA, Moreira LF et al. Randomized comparative study of radial artery and right gastroepiploic artery in composite arterial graft for CABG. [see comment]. Eur J Cardiothorac Surg 2002; 21:1009–1014.
3. Voutilainen S, Verkkala K, Jarvinen A et al. Angiographic 5-year follow-up study of right gastroepiploic artery grafts. Ann Thorac Surg 1996; 62:501–505.
4. Formica F, Greco P, Colagrande L et al. Right gastroepiploic artery graft: long-term clinical follow-up in 271 patients — experience of a single center. J Card Surg 2006; 21:539–544.
5. Formica F, Ferro O, Greco P et al. Long-term follow-up of total arterial myocardial revascularization using exclusively pedicle bilateral internal thoracic artery and right gastroepiploic artery. Eur J Cardiothorac Surg 2004; 26:1141–1148.
6. Dietl CA, Benoit CH, Gilbert CL et al. Which is the graft of choice for the right coronary and posterior descending arteries? Circulation 1995; 92:92–97.
7. Takahashi K, Daitoku K, Nakata S et al. Early and mid-term outcome of anastomosis of gastroepiploic artery to left coronary artery. Ann Thorac Surg 2004; 78:2033–2036.
8. Hirose H, Amano A, Takahashi A et al. Bypass to the distal right coronary artery using in situ gastroepiploic artery. J Card Surg 2004; 19:499–504.
9. Albertini A, Lochegnies A, El KG et al. Use of the right gastroepiploic artery as a coronary artery bypass graft in 307 patients. Cardiovasc Surg 1998; 6:419–423.
10. Jegaden O, Eker A, Montagna P et al. Technical aspects and late functional results of gastroepiploic bypass grafting (400 cases). Eur J Cardiothorac Surg 1995;9(10):575-80.
11. Suma H, Isomura T, Horii T, Sato T. Late angiographic result of using the right gastroepiploic artery as a graft. J Thorac Cardiovasc Surg 2000;120(3):496-8.
12. Suma H, Amano A, Horii T et al. Gastroepiploic artery graft in 400 patients. Eur J Cardiothorac Surg 1996;10(1):6-10.
13. Kamiya H, Watanabe G, Takemura H et al. Total arterial revascularization with composite skeletonized gastroepiploic artery graft in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2004;127(4):1151-7.
14. Fukui T, Takanashi S, Hosoda Y et al. Total arterial myocardial revascularization using composite and sequential grafting with the off-pump technique. Ann Thorac Surg 2005;80(2):579-85.
15. Manapat AE, McCarthy PM, Lytle BW et al. Gastroepiploic and inferior epigastric arteries for coronary artery bypass. Early results and evolving applications. Circulation 90(5 Pt 2):II144-7, 1994.
16. Grandjean JG, Boonstra PW, den Heyer P et al. Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients. Journal of Thoracic & Cardiovascular Surgery 107(5):1309-15; discussion 1315-6, 1994.