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Coronary Artery Bypass Grafting Using the Gastroepiploic Artery

Editor: Dipesh Ludhwani Updated: 1/31/2025 4:55:45 PM

Introduction

Coronary artery bypass grafting (CABG) has been the mainstay treatment for coronary artery disease for several decades. Various conduit options have been attempted and studied to find the best vessel to optimize surgical outcomes.[1] The literature describes multiple conduit options with particular benefits and complication rates. The saphenous vein graft, for example, is well documented in the literature as prone to atherosclerotic changes and is inferior in long-term patency rates compared to internal mammary artery grafts. The gastroepiploic artery (GEA) graft is another conduit option described in the late 1960s in the Vineberg procedure performed by Bailey et al where intramyocardial revascularization was done using the right GEA.[2] 

Sterling Edwards et al in the late 1970s attempted a direct anastomosis of the GEA to the right coronary artery.[3][4] Since then, the GEA graft has been used as an alternative graft in several other documented landmark procedures. However, Pym in Canada and Suma in Japan are credited with popularizing the GEA as a viable coronary bypass conduit.[5][6] These cases depict the various CABG anastomosis techniques that can be performed using the GEA. A CABG using a GEA conduit has the benefit of long-term patency and has been shown to provide optimal postoperative quality of life.[7][8][9][10] This course will discuss the anatomy of the GEA, indications for CABG with GEA, contraindications, the surgical technique, possible complications, and clinical significance. 

Anatomy and Physiology

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Anatomy and Physiology

The right GEA is the gastroduodenal artery's largest terminal branch, which originates from the hepatic artery. In some cases, the right GEA may arise from the left hepatic artery, the celiac trunk, or, more rarely, the superior mesenteric artery. The right GEA typically supplies approximately half to two-thirds of the greater curvature of the stomach, often forming an anastomosis with the left GEA.[11][12] At its origin, the right GEA has a diameter of about 3 mm, tapering to 1.5 to 2 mm near the middle of the greater curvature, making it a suitable conduit for CABG.

Histologically, the GEA is more muscular than the internal mammary artery (IMA), with a tunica media rich in smooth muscle cells, which increases its susceptibility to surgical spasms when handled surgically. However, it is less prone to atherosclerosis compared to coronary arteries.[13][14] The GEA contracts more powerfully in response to vasoactive drugs, including ergonovine, serotonin, and phenylephrine, than the IMA. Hence, it is important to prevent spasms of the GEA caused by adrenergic agents or platelet aggregators.[15][16] Unlike the IMA, histamine induces dilation of the GEA, and its blood flow increases after meals.[17] These unique properties, including its caliber, muscularity, and resistance to atherosclerosis, make the GEA an excellent choice as a conduit for CABG.

Indications

Indications for CABG using the GEA include but are not limited to the following:

  • Distal right coronary artery (RCA) and posterior descending artery (PDA) grafting
    • The GEA is ideal for grafting the distal RCA and PDA, given its proximity to these vessels and the distance of these targets from the right IMA.
  • Distal left circumflex artery or left anterior descending artery grafting
    • The GEA can be used to graft the distal left circumflex artery or left anterior descending artery when the IMA is unavailable or unsuitable for grafting.
  • Aortic no-touch technique
    • For patients with atherosclerotic ascending aortas, the in-situ GEA graft facilitates the aortic no-touch technique, reducing the risk of embolic complications.[18]
  • Redo CABG
    • The GEA is particularly advantageous in redo CABG procedures due to its ease of mobilization from the abdomen before a redo sternotomy. Additionally, when only the inferior wall requires revascularization, the GEA allows for a minimal subxiphoid transabdominal approach, potentially eliminating the need for cardiopulmonary bypass.

Contraindications

There are no absolute contraindications for CABG. Relative contraindications include the following:

  • Asymptomatic individuals at low risk of myocardial infarction or death
  • Elderly patients, especially those aged 85 and older 
  • Obesity and morbid obesity 
  • Deconditioning or debilitated individuals
  • Hemodynamic instability 
  • Severe pulmonary disease 
  • Previous/future abdominal surgeries
  • Life expectancy

Equipment

Equipment for CABG using GEA graft is similar to other CABG procedures and includes but is not limited to the following:

  • Surgical operating room
  • Sterile drapes, gown, and gloves
  • Sternotomy saw
  • Electrocautery
  • Coronary scissors
  • Dissecting scissors
  • Needle holders
  • Straight forceps
  • Ring tip forceps
  • Micro teeth forceps
  • Clamps various sizes
  • Suction to clear the field
  • Vessel dilators and probes
  • Temporary occlusion tips
  • Diluted papaverine hydrochloride
  • Silk ligatures
  • Harmonic scalpel
  • Graft markers
  • Vessel loops
  • Punches 
  • Sutures

Personnel

Several personnel are required for the different phases of the CBG procedure. They include the following:

Preoperative

  • Primary care clinician
  • Structural heart specialist
  • Interventional cardiologist
  • Cardiothoracic surgeon  
  • Heart failure specialist (in certain cases)

Intraoperative

  • Cardiothoracic surgeon specializing in CABG
  • Surgical first assistant
  • Surgical nurse 
  • Nurse assistant
  • Surgical technician 
  • Anesthesiologist 

Postoperative

  • Postoperative nurse
  • Cardiac rehabilitation specialist
  • Cardiac nutritionist

Preparation

Proper preparation for CABG is essential to optimize outcomes and minimize complications. This includes:

  • Smoking cessation
    • Patients are advised to cease smoking at least 8 weeks before surgery to improve wound healing, reduce respiratory complications, and enhance overall recovery.
  • Antiplatelet management
    • Discontinue P2Y12 inhibitors (eg, clopidogrel) at least 5 days before surgery to minimize bleeding risk. Aspirin may be continued unless contraindicated.
  • Antibiotic prophylaxis
    • On the day of the procedure, intravenous antibiotics are administered to prevent surgical site infections, typically within 60 minutes before the incision.
  • Informed consent
    • Clinicians should clearly explain the surgical technique, including any specific conduit options like the gastroepiploic artery and associated risks such as infection, bleeding, myocardial infarction, or stroke. The discussion should include the anticipated benefits and potential alternatives, such as medical management or percutaneous coronary interventions. Patients should be able to ask questions and provide voluntary, documented consent.
  • General anesthesia
    • CABG requires general anesthesia, ensuring patient immobility, comfort, and control of vital parameters during this invasive procedure.

These measures are part of a comprehensive perioperative strategy to enhance patient safety and surgical success.

Technique or Treatment

Harvesting Techniques

The GEA can be harvested using a pedicled or skeletonized approach. Recently, it was discovered that skeletonized GEA conduits have higher patency rates than their pedicled counterparts. A median sternotomy incision is extended inferiorly around 5 to 6 cm longer than the standard incision for CABG, opening the peritoneum and the stomach delivered into the surgical field. The GEA is identified, traced, and gently handled to prevent spasms. 

The GEA is then mobilized from the greater curvature of the stomach as a pedicle with surrounding tissue or skeletonized, keeping the conduit as long as possible. Electrocautery is used to achieve hemostasis to prevent hematoma formation in the pedicle and cauterize vessels in the omentum. Silk ligatures are used for branch vessels to secure hemostasis. The GEA is then divided distally, and diluted papaverine or nitroprusside hydrochloride is injected into its lumen to minimize the risk of vascular spasms. The distal end is later clamped, which achieves good caliber and adequate distension of the GEA due to papaverine and the effect of its own blood pressure, which is important to achieve satisfactory anastomosis.

The graft length is decided by calibrating the distance from the anastomotic site. Approximately 2 to 3 cm of the artery is skeletonized, and the gastroepiploic vein is ligated. A harmonic scalpel is used to harvest the GEA. The greater omentum is opened, its anterior layer is divided, and the GEA is traced entirely in order to cauterize all its small gastric and omental branches. After ensuring thorough hemostasis, the GEA is enveloped in a papaverine-soaked sponge to prevent spasms and remain relaxed. Thereafter, a small incision is made in the anterior aspect of the diaphragm through which the GEA conduit is brought up into the pericardial cavity, traversing the anterior surface of the stomach and the liver. The end of the pedicle is then transfixed to the anterior edge of the diaphragm to ensure fixity. Alternatively, fibrin glue can be used to fix the graft and prevent its torsion.

Grafting Techniques

Under cardioplegic arrest or an off-pump beating heart, the coronary artery anastomosis of the GEA is performed. Using a 7-0 or 8-0 polypropylene suture, a few running sutures are placed at the heel of the coronary artery and the GEA. The rest of the anastomosis is completed using a single continuous suture. Depending on the site and artery involved, the anastomosis could be antegrade or retrograde. Hemostasis is confirmed before the release of the aortic cross-clamp. Twisting or kinking of the GEA due to improper fixation near the perianastomotic site must be avoided. The pedicle of the GEA is now fixed to the epicardium. Thorough hemostasis is performed, the patient is weaned off cardiopulmonary bypass, and the closing of the chest and abdominal wounds takes place. A drain may be placed in the abdominal cavity if required. The patient should be monitored in the immediate postoperative period in the intensive care unit, usually for about 1 week.

In repeat CABG targeting only the right coronary artery (RCA) territory, the right GEA can be used through a minimally invasive approach without requiring sternotomy. A small laparotomy is performed using an 8- to 10-cm midline incision over the previous sternotomy scar, extending above the xiphoid. This incision allows for the excision of the xiphoid process, placement of a standard sternal retractor, and adequate exposure of the inferior wall of the heart while facilitating access to the upper abdomen for GEA harvesting.

The diaphragmatic surface of the heart is dissected to expose the inferior wall, and the distal segments of the RCA are identified to determine the optimal anastomotic target. The peritoneum is then opened, and the GEA is harvested and routed between the pericardial layers. A suction stabilizer is secured cranially on the retractor, with its branches positioned close to the target coronary artery to ensure stability during the anastomosis. Following the completion of the anastomosis, fibrin glue is applied around the site to prevent torsion of the GEA conduit.

A small drainage tube is then placed in the pericardium, and the incision is closed in a routine fashion. This off-pump technique provides a focused and efficient approach to revascularization in repeat CABG. Postoperative protocols for patients receiving a skeletonized GEA graft typically do not require calcium channel blockers. This contrasts with radial artery grafts, where calcium channel blockers may be necessary to maintain conduit patency and prevent spasms.

Grafting Philosophy

Considering its proximity, the distal RCA and its posterior descending and posterolateral branches are the most suitable targets for GEA grafting. The GEA is typically usedt as an in situ graft passing through the diaphragm, with sufficient length to reach most RCA targets and, in some cases, distal circumflex branches. Sequential grafting can be performed to revascularize multiple coronary targets using a single GEA, a technique facilitated by the skeletonization of the vessel. The GEA can also be used as a free graft in Y or I formation with the IMA or the radial artery. For optimal outcomes, the target coronary artery should exhibit significant stenosis exceeding 90% to minimize the risk of graft spasm or failure due to competitive flow from native vessels.[19][20][21]

Complications

The following complications may arise during the CABG procedure. Remaining vigilant is important to avoid or manage complications.

Intraoperative Complications

  • Hemorrhaging/hematoma formation (from branches of the GEA into the omentum and stomach)
  • Kinking/twisting of the pedicle as it is brought up through the diaphragm and again at the perianastomotic site (a complication due to improper operative technique)
  • Arrhythmias (including atrial fibrillation, ventricular tachycardias, and bradycardias)
  • GEA spasm
    • Due to its higher content of smooth muscle cells, the GEA is more prone to spasming in the perioperative period due to mishandling or inotropic effects.

Postoperative Complications

  • Perioperative myocardial infarction
  • Graft occlusion
  • Low cardiac output
  • Vasodilatory shock
  • Arrhythmias (including atrial fibrillation, ventricular tachycardias, and bradycardias)
  • Pericarditis/myocarditis
  • Pericardial effusion/tamponade
  • Late recurrent angina pectoris [22]

Clinical Significance

The right GEA is an excellent conduit for CABG. Extensive studies' results have shown that this artery undergoes minimal atherosclerotic changes and does not increase surgical complications, either cardiac or abdominal. Significantly, it doesn't induce gastric ischemic after mobilization and has survival and patency rates comparable to the IMA grafts. Hence, the GEA graft is considered safe and a technically sound arterial conduit for CABG.[23]

Enhancing Healthcare Team Outcomes

The success of coronary artery bypass grafting relies on the coordinated efforts of a skilled interprofessional team. Cinicians and surgeons must apply advanced diagnostic and technical skills, using imaging and surgical expertise to plan and execute revascularization effectively. Advanced clinicians and nurses play a critical role in preoperative patient education, explaining the procedure, addressing concerns, and emphasizing the importance of lifestyle modifications, such as smoking cessation. Pharmacists ensure accurate medication management, particularly by optimizing antiplatelet therapy and adjusting dosages of anticoagulants or other cardiac medications to minimize perioperative risks.

Effective interprofessional communication and care coordination are essential throughout the perioperative period. Nurses and advanced clinicians monitor patients closely, recognizing and addressing potential complications like arrhythmias, infection, or hemodynamic instability. Timely communication with clinicians enables swift interventions. Postoperative care benefits from a cohesive strategy involving physical therapists and dietitians to support recovery and long-term health improvements. This collaborative approach prioritizes patient-centered care, improves outcomes, enhances safety, and optimizes team performance.

References


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