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ObjectiveWe analyzed the angiographic changes of the anastomotic sites at three time points for 5 years after off-pump coronary artery bypass surgery.MethodsOf the 402 patients who underwent off-pump coronary artery bypass surgery between January 1998 and December 2001, 240 patients who received the early, 1-year, and 5-year follow-up coronary angiograms regardless of the patient's anginal symptoms were studied. Morphologic changes of grafts were traced by the FitzGibbon grading system.ResultsOverall graft patency rates (FitzGibbon grade A+B) at early, 1-year, and 5-year angiography were 98.6%, 91.9%, and 88.3%, respectively. Graft patency rates in the left anterior descending artery, left circumflex artery, and right coronary artery territories were similar at early angiograms (P = .162). However, graft patency rate in the left anterior descending artery territory was higher than that in the left circumflex artery and right coronary artery territories at both the 1-year (P < .001) and 5-year (P < .001) angiograms. Of the 31 FitzGibbon grade B arterial grafts (internal thoracic artery and right gastroepiploic artery) at early angiography, 10 became occluded and 19 became grade A at 5-year angiography. In the saphenous vein grafts, grade B lesions gradually increased during the 5 postoperative years (2.6% vs 6.5% vs 13.3%).ConclusionsMidterm angiographic follow-up demonstrated acceptable patency rates of grafts after off-pump coronary artery bypass surgery. Approximately half of the FitzGibbon grade B arterial grafts in the early angiograms became grade A at 5 years after surgery, but the proportion of grade B saphenous vein grafts gradually increased over the 5 postoperative years.

ObjectiveWe performed early postoperative angiography to assess anastomosis accuracy and patency after off-pump coronary artery bypass grafting.MethodsOne thousand three hundred forty-five patients who underwent off-pump coronary artery bypass grafting between January 1998 and December 2007 were studied. Grafts for distal anastomoses were left internal thoracic artery (n=1281), right internal thoracic artery (n=679), right gastroepiploic artery (n=836), radial artery (n=14), and saphenous vein (n=188). Groups underwent off-pump coronary artery bypass grafting without (group I, n=234) or with (group II, n=1111) intraoperative graft flowmetry. Early postoperative (≤7 days) angiography was performed in 1278 cases (95.0%) at 1.6±1.2 postoperative days.ResultsOperative mortality was 1.6%. Average number of distal anastomoses was 3.0±1.0. Postoperative angiography showed early patencies of 98.9% for arterial grafts and 88.2% for venous grafts (P < .001). In group II, intraoperative flowmetry-guided revision was performed in 2.2% of distal anastomoses. Patency of arterial grafts was significantly higher in group II than group I (97.2% vs 99.1%, P < .001); however, patency of venous grafts was not significantly different (86.0% vs 92.2%, P=.099). Early reoperation for graft revision according to angiographic findings was performed in 35 patients.ConclusionsEarly patency of venous grafts was significantly lower than that of arterial grafts. Intraoperative flowmetry and revision of abnormal grafts improved early graft patency, and reoperation according to early angiographic findings may further improve graft patency.

To perform coronary artery bypass grafting safely for patients with calcified ascending aorta, an "aortic no-touch technique," which consisted of (1) maximal utilization of In situ arterial grafts, (2) fibrillatory arrest without aortic cross-clamp, (3) left ventricular venting through the right superior pulmonary vein, and (4) femoral artery perfusion, was attempted in 3 patients. All were men, aged 64, 70, and 56 years, respectively, with triple-vessel disease with severe atherosclerotic lesion in the ascending aorta. Bilateral internal mammary arteries and the right gastroepiploic artery were used in all patients. All patients survived without evidence of perioperative myocardial infarction or cerebrovascular accident.

Objective: The angiographic patency of the right gastroepiploic artery graft used for coronary artery bypass grafting was studied during the late (5-10 years) postoperative period. Methods: Among 936 patients undergoing a gastroepiploic artery graft for coronary artery bypass grafting between 1986 and 1999, postoperative angiographic restudy was conducted on 685 patients within 1 year (mean, 2.2 months), on 102 patients between 1 and 5 years (mean, 2.3 years), and on 52 patients between 5 and 10 years (mean, 7.8 years). Results: The patency rate of the gastroepiploic artery graft was 94%, 88%, and 83% in each restudy group. The cumulative patency rate estimated by the Kaplan-Meier method was 96.6% at 1 month, 91.4% at 1 year, 80.5% at 5 years, and 62.5% at 10 years. Causes of late occlusion were primary anastomotic stenosis and anastomosis to a less critically stenosed coronary artery. Once the gastroepiploic artery was perfectly anastomosed to the coronary artery, which has tight stenosis and good runoff, late patency was good, and new stenosis in both the gastroepiploic artery trunk and the anastomotic site was uncommon. Conclusion: The gastroepiploic artery graft can be used effectively for coronary artery bypass for the long term with proper target selection. (J Thorac Cardiovasc Surg 2000;120:496-8)

Patient initials or identifier number S.M. ### Relevant clinical history and physical exam A 57-year-old man was admitted to our institution complaining of abdominal pain. He had a history of laparotomy for harvesting the right gastroepiploic artery (rGEA) and had previously received coronary

Although the placing of a pedicle of omentum to wrap replaced aorta in an infected field is a well established procedure, there have been few reports that have demonstrated the postoperative vascular supply to such omental wraps. In our series of patients undergoing this procedure, postoperative selective angiography of the right gastroepiploic artery (RGEA) was performed in one case, and showed well developed vascularity of the omentum surrounding the replaced graft. This ample blood supply might explain the role played by omentum in the prevention of postoperative graft infection.

Most gastroplasties performed to replace the esophagus are vascularized by the right gastroepiploic artery alone. Its origin, course and anatomical relations are classical and subject to little variation. Conversely, its mode of termination and relations to the left gastroepiploic artery have received quite different descriptions in the literature. This report describes the radiological anatomy of the right gastroepiploic artery based on arteriograms in 50 subjects. The right gastroepiploic artery was much larger (diameter 1.7 to 2.6 mm at its origin) than the left (absent in 3 cases) in our series. Direct end-to-end anastomosis of these two arteries, as described in classical reports, was found in only 23.5% of cases.

We compared patients who received an internal-mammary-artery graft to the anterior descending coronary artery alone or combined with one or more saphenous-vein grafts (n = 2306) with patients who had only saphenous-vein bypass grafts (n = 3625). The 10-year actuarial survival rate among the group receiving the internal-mammary-artery graft, as compared with the group who received the vein grafts (exclusive of hospital deaths), was 93.4 percent versus 88.0 percent (P = 0.05) for those with one-vessel disease; 90.0 percent versus 79.5 percent (P less than 0.0001) for those with two-vessel disease; and 82.6 percent versus 71.0 percent (P less than 0.0001) for those with three-vessel disease. After an adjustment for demographic and clinical differences by Cox multivariate analysis, we found that patients who had only vein grafts had a 1.61 times greater risk of death throughout the 10 years, as compared with those who received an internal-mammary-artery graft. In addition, patients who received only vein grafts had 1.41 times the risk of late myocardial infarction (P less than 0.0001), 1.25 times the risk of hospitalization for cardiac events (P less than 0.0001), 2.00 times the risk of cardiac reoperation (P less than 0.0001), and 1.27 times the risk of all late cardiac events (P less than 0.0001), as compared with patients who received internal-mammary-artery grafts. Internal-mammary-artery grafting for lesions of the anterior descending coronary artery is preferable whenever indicated and technically feasible.

Splenectomy was performed in 15 crossbred dogs; hilar vessel ligation was used in eight dogs (group 1) and splenic and short gastric artery ligation were used in seven (group 2). Blood flow to six sites along the greater and lesser curvatures of the stomach was recorded with radioactive tracer microspheres. A significantly higher blood flow was recorded in group 2 for the site supplied by the right gastroepiploic artery (p = 0.0441). There was no difference between the groups for the site supplied by the left gastroepiploic and short gastric arteries. Histologically, there was no difference in gastric tissue samples from four sites. Splenic and short gastric artery ligation did not compromise stomach blood flow or the integrity of the stomach wall, and may be superior for splenectomy because of its relative simplicity and potentially shorter operative time.

We describe the angiographic technique of grafting the right gastroepiploic artery to the coronary artery. With the femoral approach, our specially devised catheter was placed in the common hepatic artery or gastroduodenal artery. The gastroepiploic artery and graft to the coronary artery were visualized satisfactorily by manual injection of contrast media.

Multiple coronary artery bypass grafting with more than 4 grafts has been carried out in 64 Japanese patients during a 3.5 year period. There were 55 males and 9 females; ages ranged from 34 to 75 with a mean of 58.9 years old. Double, triple and left main disease were noted in one (2%), 54 (84%) and 9 (14%) patients, respectively. There was 54 (84%) stable and 10 (16%) unstable angina pectoris, and 28 (44%) patients had previous myocardial infarction. The saphenous vein graft was used for all patients with a preferential use of sequential graft (84%). The internal mammary artery graft was used in 55 (86%) patients and the right gastroepiploic artery graft was used in 6 (9%) patients. There were 2 (3.1%) early and 2 (3.1%) late deaths. New Q wave was noted in 2 (3.1%) patients and intraaortic balloon pumping was required in 3 (4.7%) patients. The mean number of grafts was 4.4 ranged from 4 to 7, and the mean aortic cross clamp time and cardiopulmonary bypass time was 74.5 min and 134.3 min, respectively. Graft patency within 6 postoperative months was 86% (120/140) in saphenous veins, 96% (52/54) in internal mammary arteries and 100% (5/5) in gastroepiploic arteries. Relief of angina was noted in 58 (96.7%) of 60 survivors. It was concluded that the increase in the number of coronary artery anastomoses does not increase surgical risk and favorable outcome and acceptable graft patency can be obtained by multiple grafting for patients with severe multivessel coronary artery disease.

Experience with 39 patients (32 men, 7 women) undergoing coronary artery bypass grafting with the right gastroepiploic artery (RGEA) is reported. Indications initially included poor-quality or absent saphenous vein, ascending aortic atherosclerosis, and repeat coronary artery bypass grafting. The average number of grafts per patient was 4.10. Arteries bypassed were the posterior descending (22 patients), right coronary (12), diagonal (5), and marginal (4). Distal RGEA internal diameters of all grafts measured 1.5 to 3.25 mm (average diameter, 2.14 mm). Pedicled graft lengths measured 18 to 30 cm (average length, 23.7 cm), and free grafts, 8 to 24 cm (average length, 17.7 cm). In 6 patients, no vein grafts were used, and in all patients, at least one internal mammary artery graft was placed. Early postoperative cardiac catheterization (19 pedicled and ten free grafts) in 29 patients revealed all grafts to be patent without a kink or twist, but three of these free RGEA grafts had vasospasm. Advantages of RGEA grafts are as follows: (1) it is a third arterial conduit with artery-artery anastomoses of comparable sizes; (2) a shorter leg incision or no leg incision is necessary; (3) it can be harvested simultaneously with the internal mammary artery and the saphenous vein; (4) the proximal anastomosis (free grafts) is easy; (5) its use avoids bilateral internal mammary artery grafts in patients at high risk for sternal infection; and (6) atherosclerotic ascending aortas are not clamped. Subintimal hyperplasia and atherosclerosis of RGEA grafts are unlikely.(ABSTRACT TRUNCATED AT 250 WORDS)

A four-phased experimental program to develop an effective method for revascularization of the “posterior” wall of the left ventricle was undertaken in the fall of 1963. All experiments involving intramyocardial implantation of “new” arteries created by grafting techniques (autologous venous or arterial segments) proved disappointing. Finally reasoning that such necessarily totally denervated graft “arteries” would not respond to what Vineberg12 has called “arteriotaxis” like normally innervated arteries (such as the internal mammary) a search was made for a suitable “expendable” abdominal artery. The right gastroepiploic artery was chosen as best fulfilling the various assumed requirements and a series of animals was submitted to “implant revascularization” with a pedicle containing this artery. The experimental results with respect to prolonged patency and eventual vascular communication with the natural coronary arterial branches were essentially identical to those seen with the implanted internal mammary artery. A clinical series of 27 patients, chosen and monitored with the help of selective coronary cineangiography was commenced. Only patients with clearly delineated severe obstructive disease of one or more of the major coronary trunks were selected. The procedure, even when combined with anterior implantation of the internal mammary artery, proved to be well tolerated even in older patients (oldest 72). Excluding patients less than one month postoperatively (seven) all but one of the survivors report significant improvement with respect to anginal pain. Nine of the series report dramatic relief—essentially no pain under conditions of normal living. Injection studies (at necropsy) of the heart of the one patient in this series who died of unrelated causes four months after a double implant operation revealed early and equal development of anastomosis from the internal mammary and right gastroepiploic arteries to the respective contiguous distal coronary arterial branches. This evidence, while promising, does not yet constitute final proof of the validity of this proposed method for revascularization of the posterior myocardium. However, theoretical presumptions based upon the structural similarities between the anterior and posterior ventricular walls and the similarities in behavior of the implanted gastroepiploic and internal mammary arteries encourage us to continue this study.

Acute gastric hemorrhage in a 43-year-old woman with hepatic failure and a severe coagulation defect was successfully controlled by selective embolization of the bleeding right gastroepiploic artery. The technique and the risk of embolization are discussed.

The ramification of the pancreatic arteries, including the lobular vessels, was studied in 36 mongrel dogs by means of plastic injection and corrosion, as well as microangiography. The left pancreatic lobe receives the left cranial pancreatic artery and other smaller branches from the splenic artery, and two to four twigs from the gastroduodenal artery. In addition, it receives very often a branch from the common hepatic artery. Branches arising from the cranial mesenteric artery and from the first jejunal artery may also be found. The right cranial pancreatic artery and the right gastroepiploic artery give branches to the pancreatic angle. The arteries to the right pancreatic lobe arise from the cranial and from the caudal pancreaticoduodenal arteries. The interlobular arteries give origin to the intralobular arteries. The penetration and the distribution of the latter vessels differ in lobules of different shape. The intralobular course may be straight or curved. Branches arise generally at acute angles, forming Y or fork-like patterns, ending into bundles of arterioles.

Chronic encapsulated mediastinal abscess is an unusual complication of previous open heart surgery. We report on the case of a 79 year old male who presented with epigastric fistulization of an encapsulated anterior mediastinal abscess 12 years after a redo aortic valve replacement for prosthetic valve endocarditis. The encapsulated abscess and its complex branching tracts and the cutaneous fistula were excised completely except the thin longitudinal strip of the ascending aorta which formed part of the posterior wall of the infected tract. This was covered with transposed greater omentum based on right gastroepiploic artery pedicle. Patient remains fit and well 2 years after his operation. This report is unusual on account of the length of the interval between previous heart surgery and the infective complication, the presumed dormancy of the abscess for as long as 12 years, the complex course, branching tracts and the contents of the abscess, the remote fistulization of the abscess at a distant anatomical site and, finally, the principle of successfully covering an infected tract which formed the adventia of the ascending aorta with pedicled omentum in the hope of avoiding an ascending aortic replacement in a frail 79 year old man. In the entire English language literature, this report represents the longest interval between a heart operation and a sternal or mediastinal abscess

This study is focused on the vascular anatomy of the stomach in relation to the gastric pull-up construction. The vascular anatomy was studied on forty-one human specimens. We find out the differences in blood supplement between anterior and posterior wall. It was maked an review of the main trunk arteries of the stomach. To display the vessels of the stomach we used diaphanoscopy, digital shooting in special mode and micro preparation of the vessels. We find out that left gastric artery gives more branches to the posterior wall and right gastroepiploic artery (RGEA) gives more branches to the anterior wall. But brunches of RGEA are longer on the posterior wall than on the anterior. Also we are offering the new classification of the RGEA related to gastric pull-up construction. This classification based not only on the anatomical shapes of RGEA but on the properties of the flow dynamics through the artery.

Background: Atherosclerotic or calcified ascending aorta is an important predictor of adverse cerebrovascular events. Using off-pump coronary artery bypass (OPCAB) with composite and in situ arterial grafting to avoid aortic manipulation and clamping may reduce the risk of stroke related to aortic atheroembolism. When the aorta is calcified and cannot serve as a safe site for proximal anastomosis, this anastomosis can be performed on the proximal segment of the right internal thoracic artery (ITA) and right gastroepiploic artery (RGEA). Four such cases are described. Methods: In 2 patients, the proximal right ITA was used as the site for proximal saphenous vein graft (SVG) anastomosis. Chronic obstructive lung disease in one patient and insulin-dependent diabetes in the other precluded performance of OPCAB with bilateral ITA. In addition, positive Allen test precluded performance of composite T-graft with radial artery (RA) on ITA. Both SVGs were anastomosed distally to the posterior descending artery. In 2 other patients, RA was connected end-to-side to the proximal segment of the RGEA. Both of these patients had repeat operations. The distal end of the RGEA was too small, and concerns regarding the future flow to a very large coronary bed precluded its use as an in situ graft. Results: All patients underwent the operative procedures without any neurological or cardiovascular adverse effects, and all are midterm, symptom-free survivors. Postoperative graft patency was confirmed intraoperatively with flow measurements and postoperatively with control angiography or coronary imaging computed tomography. Conclusions: The RITA and proximal RGEA can serve safely as sites for proximal anastomosis in patients with atherosclerotic calcified aorta undergoing OPCAB.

Introduction Spontaneous rupture of the right gastroepiploic artery is an extremely rare case which can be a cause of abdominal apoplexy. Case report We present a case of a 64-year old woman with a Spontaneous rupture of the right gastroepiploic artery with hemorrhagic shock that was successfully treated by emergency surgery. Conclusion Simultaneous restoration of circulating volume and rapid diagnosis are keys in determining the patient outcome in this situation. Though the mortality is high if untreated, the operation is relatively simple and carries a low risk.