Off pump Intraabdominal Rerouting Of Patent Gastroepiploic Arterial Grafts At The Time Of Laparotomy After Coronary Artery Bypass Grafting
Tomohiro Mizuno, Keiji Oi, Masafumi Yashima, Eiki Nagaoka, Tsuyoshi Hachimaru, Hidehito Kuroki, Dai Tasaki, Tatsuki Fujiwara, Masashi Takeshita, Ryoji Kinoshita, Hirokuni Arai.
Tokyo Medical and Dental University, Graduate School of Medical and Dental Science, Tokyo, Japan.
OBJECTIVE: Right gastroepiploic artery (GEA) grafts have been utilized for severely stenotic right coronary arteries because the GEA can provide good patency after coronary artery bypass grafting (CABG). However, abdominal surgery in patients with patent GEA grafts has been of concern because of adhesions or the need to resect the GEA.
METHODS: At our institution, the GEA has been used in approximately 300 patients since 1991, and we performed 12 laparotomies in 9 patients with a patent GEA. We investigated the results and management of the patent GEA in those 9 patients.
RESULTS: The mean duration from CABG to laparotomy was 92 months (21-180 months). The abdominal adhesions around the GEAs were minimal in all cases. The GEA could be preserved in 6 of the 9 patients (gastric cancer in 4 patients, duodenal papilla cancer in 1 patient and cholecystitis in 1 patient), and rerouting of the GEA was necessary in 3 patients who had pancreatic cancer or cholangiocarcinoma, because the proximal portion of the GEA had to be resected with the cancers. Off-pump intra-abdominal rerouting of the GEA at the time of laparotomy for the cancers was performed instead of redo CABG via resternotomy. After laparotomy, the patent GEA was exposed, and a branch of the celiac artery that could be preserved was also exposed. After heparinization, the branch was clamped, and a short saphenous vein was anastomosed to the branch (the primary hepatic artery in 2 patients, and left gastric artery in 1 patient). Then, the GEA was incised near the liver, and an intraluminal coronary shunt tube was inserted into the GEA to perfuse the grafted coronary artery, and the saphenous vein was anastomosed to the GEA. After confirmation of good saphenous vein graft flow, the proximal part of the GEA was ligated and resected. After rerouting of the GEA, pancreaticoduodenectomy was performed with no cardiac event.
CONCLUSIONS: Laparotomy for patients with patent GEA coronary grafts can be safely performed, and intra-abdominal rerouting of the GEA with a short saphenous vein is thought to be a good option if pancreaticoduodenectomy is necessary.
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