Heparin-coated shunts for lesions of the descending thoracic aorta. Experimental and clinical observations

Heparin sodium-coated shunts are employed frequently to maintain trunk and lower extremity perfusion during temporary occlusion of the descending thoracic aorta. In the past five years, this shunt has been used in a series of 39 patients ranging in age from 19 to 72 years old, with 34 survivors (87%). The proximal end of the shunt was placed in the subclavian artery in 17 patients, the left ventricle in ten, and in the ascending or transverse aortic arch in 12. The distal end of the shunt was placed either in the lower thoracic aorta or in the femoral artery. For further evaluation of effectiveness, paired observations were made in dogs to determine the physiological consequences with the proximal end of the shunt inserted at two different sites. Although neither shunt decompressed the left ventricle fully, the subclavian-femoral shunt was significantly more effective than was the left ventricle-femoral artery bypass. If a choice exists for sites of insertion of the shunt, it appears that it should be placed distal to the aortic valve, since this position provides the least increase in systolic blood pressure and is associated with a lower demand for myocardial blood flow.     

Successful aorto-circumflex coronary bypass grafting through left thoracotomy following aortic and mitral valve replacement

We report successful descending thoracic aorto-circumflex coronary artery bypass grafting using a saphenous vein graft through left thoracotomy in a 44-year-old female. The patient developed severe angina attack after aortic and mitral valve replacement. Coronary angiography showed 99% stenosis of the circumflex coronary artery. Under general anesthesia, left femoral vein to arterial partial cardiopulmonary bypass was performed via left 4 th intercostal space. Body temperature was lowered to 22 degrees centigrade, and spontaneous cardiac fibrillation occurred. After minimal exposure by pericardial dissection of the circumflex coronary artery, distal anastomosis and then proximal anastomosis at the descending thoracic aorta was carried out under cardiac fibrillation. This surgery was done with minimal intra-and postoperative bleeding. Postoperative course was very smooth, and the patient was discharged and leading a normal life for 6 months after surgery.     

Surgical treatment for aneurysms of the descending aorta using temporary perfusion by a centrifugal pump: clinical analysis of 33 cases

Since 1987, 33 patients have undergone surgery at Kobe University Hospital for aneurysm of the descending aorta using left heart bypass with a heparin-coated centrifugal pump and heparin-coated tubes. Sixteen patients had true aneurysms of the descending thoracic aorta, 7 had thoracoabdominal aneurysms, and 10 had aortic dissection (DeBakey's Type III). Heat exchangers and oxygenators were not included in the bypass circuit in any of the cases. Perfusion time was from 42 to 205 min (average 90 min). Left heart bypass was established with 1 mg/kg of systemic heparinization in 5 cases, 0.5 mg/kg in 5 cases, and 0 mg/kg in 23 cases. There were no complications such as perioperative embolism, acidosis, or hypothermia. During aortic cross-clamping, the arterial pressure of the lower extremity was maintained above 70 mm Hg, but there was no relationship between the distal perfusion pressure and bypass flow. The urine output during left heart bypass was related to the distal perfusion flow by centrifugal pump. Of 23 patients who underwent bypass with less than 40 ml/kg/min of distal perfusion flow, 7 showed transient renal dysfunction postoperatively, and 1 developed postoperative renal failure. The other patients who were bypassed with over 40 ml/kg/min of pump flow stayed in the normal range of renal function. Postoperative paresis occurred in 2 patients, who were also perfused with less than 40 ml/kg/min of bypass flow. It could be concluded that left heart bypass by centrifugal pump is safe and acceptable as a circulatory support in the surgical treatment of aneurysm of the descending aorta.(ABSTRACT TRUNCATED AT 250 WORDS)     

Initial experience using an intraluminal shunt during revascularization of the beating heart

BACKGROUND: For decades, surgeons have relied on extracorporeal circulation and induced cardiac asystole to provide a bloodless, motionless field in which to construct coronary bypass grafts. However, the technique of coronary grafting without heart-lung support is now being revitalized. The current resurgence of off-pump coronary artery bypass grafting and the advent of less invasive incisions make it imperative that technical advances be applied to maximize the safety of these procedures. METHODS: This report describes an inexpensive intraluminal shunt that maintains coronary perfusion, prevents ischemia, reduces backbleeding, and molds the suture line to prevent accidental missuturing of the posterior coronary wall. RESULTS: In 63 patients, saphenous grafts were placed to the left anterior descending (49), diagonal (9), and right coronary artery (27) without extracorporeal circulation using an intraluminal shunt. There were no deaths (0% mortality) and one perioperative infarction (1.5%). Complication and graft patency rates were comparable with those obtained by conventional techniques. CONCLUSIONS: Temporary intraluminal shunting greatly facilitates the surgeons' operative environment by permitting safe and precise construction of coronary artery grafts on the beating heart in a bloodless field. Intraluminal shunting may have future implications on the ability to perform safe and reproducible grafting on the beating heart through minimally invasive or endoscopic approaches.     

Protective effect of oral xemilofiban in arterial thrombosis in dogs: increased activity in combination with aspirin

Traumatic rupture of the thoracic aorta should be suspected when automobile (62.9%), motorcycle (11.1%), ski-doo (2.7%), deltaplane (0.9%), or skiing accidents (0.9%), cause a sudden and rapid deceleration. It was also encountered with a vertical fall of 10 meters and more (4.6%), when a pedestrian was struck by a vehicle (4.6%) or the chest damaged by a high velocity flying object (4.6%). A lateral impact was found in 33% of injured patients and 52.7% were not wearing seat belts. Ruptured aorta was found as a single lesion in only 12% of the cases and among associated orthopedic lesions (63.8%) and abdominal injuries (28.7%), about 2/3 of them involved the left side of the body. The most reliable clinical sign of descending aortic rupture is the pseudo-coarctation syndrome found in 53% in the acute phase by simple pulse palpation and in 56% with blood pressure measurements. As soon as the diagnosis is suspected, associated hypertension present in 50% should be medically treated to avoid sudden exsanguination. Surgical repair should be undertaken with a perfusion technique which is an integral part of the ressuscitation procedure. A Gott shunt was used in 81 patients and a partial left heart bypass with a Bio-Medicus pump in 25 cases. This active atrioaortic bypass is physiologically superior. The pump flow (3727 +/- 612 ml/min.) is superior to the shunt flow (2833 +/- 576 ml/min.). Proximal pressure with the pump is better controlled (111 +/- 20 mmHg) than with the shunt (152 +/- 30 mmHg) and the mean distal pressure obtained with the pump is higher (81 +/- 19 mmHg) than with the shunt (64 +/- 22 mmHg). One case of paraplegia occured (0.9%) with an unfunctionnal Gott shunt. The survival rate is 95.4% (63/66 cases) in the acute phase and 100% (42/42 cases) in the chronic phase.     

Phacotrabeculectomy with "smile" incision, punch, and single releasable suture

A 66-year-old female had ischemic heart disease due to left main lesion complicated with calcified ascending aorta, right pelvic carcinoma and liver cirrhosis. The combined operations with coronary artery bypass by left internal thoracic artery under the hypothermic ventricular fibrillation with cardiopulmonary bypass and right nephrectomy were performed successfully. Postoperatively Treadmill exercise test and scintigram revealed no ischemihc change. She is doing well. The aortocoronary bypass to left anterior descending artery using a left internal thoracic artery under hypothermic ventricular fibrillation with cardiopulmonary bypass might be one of surgical options for high risk patient.     

The inferior epigastric artery as a coronary artery bypass graft]

From January 1992 through December 1993, 31 patients underwent myocardial revascularization with the inferior epigastric artery (IEA) graft. There were one emergency case and four coronary reoperation cases. IEA grafts were taken down through the left side paramedian incision and dilated with papaverine hydrochloride solution. The distal anastomoses were made to left anterior descending (3 cases), diagonal (14 cases), obtuse marginal (9 cases), postero-lateral (I case) and right coronary artery (4 cases). The proximal anastomoses were made to the aorta (22 cases), the hood of a new vein graft (4 cases) and the hood of an old vein graft (4 cases). When IEA was not long enough to reach the ascending aorta, it was anastomosed to the internal thoracic artery (2 cases) or the gastroepiploic artery (1 case) graft. There was one hospital death, and early patency rate (within one month) was 90% (19/21). The postoperative angiography performed at 1.3 years or 2 years showed excellent IEA graft patency. These results suggested that the IEA is suitable as a coronary artery bypass graft. Further long-term patency must be evaluated.     

Antihypertensive therapy in type 2 diabetes mellitus

Fifty-seven patients with failed sclerotherapy received a mesocaval interposition shunt with an externally supported, ringed polytetrafluoroethylene prosthesis of either 10 or 12 mm diameter. Thirty-one patients had Child-Pugh grade A disease and 26 grade B; all had a liver volume of 1000-2500 ml. Follow-up ranged from 16 months to 6 years 3 months. Three patients (5 per cent) died in the postoperative period. There were two postoperative recurrences of variceal haemorrhage and one recurrent bleed in the second year after surgery. The cumulative shunt patency rate was 95 per cent and the incidence of encephalopathy 9 per cent; the latter was successfully managed by protein restriction and/or lactulose therapy. The actuarial survival rate for the whole group at 6 years was 78 per cent, for those with Child-Pugh grade A 88 per cent and for grade B 67 per cent. Small-lumen mesocaval interposition shunting achieves portal decompression, preserves hepatopetal flow, has a low incidence of shunt thrombosis, prevents recurrent variceal bleeding and is not associated with significant postoperative encephalopathy.     

Hybrid myocardial revascularization after previous left pneumonectomy

Previous intrapericardial left pneumonectomy and irradiation necessitated an unorthodox, staged approach to myocardial revascularization in a patient with unstable angina pectoris, left main artery, and three-vessel coronary artery disease. A saphenous vein bypass graft was constructed from the descending thoracic aorta to the left anterior descending coronary artery via left thoracotomy, without cardiopulmonary bypass. Two days later the patient underwent stenting of the left main and circumflex coronary arteries. Recovery was uneventful.     

Expansion of CTG repeats from human disease genes is dependent upon replication mechanisms in Escherichia coli: the effect of long patch mismatch repair revisited

OBJECTIVE: New techniques for minimally invasive coronary artery bypass grafting have recently emerged. The purpose of this study was to determine the safety and efficacy of Port-Access (Heartport, Inc., Redwood City, Calif.) coronary revascularization and to evaluate with angiography the early graft patency rate with this new approach. METHODS: From October 1996 to May 1997, 31 patients underwent Port-Access coronary artery bypass grafting with an anterior minithoracotomy and endovascular-occlusion cardiopulmonary bypass. There were 26 men and 5 women with a mean age of 62 years (range 42 to 82 years). Fifteen patients underwent single bypass; 12 patients underwent double bypass, and 4 patients underwent triple bypass. Bypass conduits included the left internal thoracic artery (n = 30), right internal thoracic artery (n = 2), radial artery (n = 10), and saphenous vein (n = 6). Three sequential grafts were used. Angiographic studies of the bypass grafts were performed in 27 of 31 patients (87%). RESULTS: There were no deaths, neurologic deficits, myocardial infarctions, or aortic dissections. Conversion to sternotomy was not required in any case. There were two reoperations for bleeding, one reoperation for tamponade, and one reoperation for pulmonary embolus. Postoperative angiography revealed anastomotic patency of the left internal thoracic artery to left anterior descending artery in 26 of 26 grafts (100%) with overall anastomotic patency in 43 of 44 grafts (97.7%). CONCLUSION: These results demonstrate that Port-Access coronary artery bypass can be performed accurately and safely with acceptable morbidity. This approach allows for multivessel revascularization on an arrested, protected heart with excellent anastomotic precision and reproducible early graft patency.     

Clinical and hemodynamic criteria for use of the intra-aortic balloon pump in patients requiring cardiac surgery

In order to establish criteria for elective use of the intra-aortic balloon pump (IABP) in patients having cardiac surgery, we conducted a retrospective study of 43 patients who required counterpulsation, because of inability to be weaned from cardiopulmonary bypass, between May, 1972, and June, 1974. Patients in cardiogenic shock preoperatively were excluded. The 43 patients included 23 (Group A) who had severe preoperative left ventricular dysfunction with a mean cardiac index less than 1.8 L. per minute per square meter, ejection fraction less than 30 per cent, and end-diastolic pressure greater than 22 mm. Hg; 20 patients (Group B) had a combination of moderate cardiac dysfunction (cardiac index less than 2.2, ejection fraction less than 40, end-diastolic pressure less than 18) in the presence of acute infarction or severe aortic stenosis (gradient greater than 80 mm. Hg) with or without coronary disease. An inverse relationship was noted between survival and delay from completion of operation to the use of 1ABP. Thirty-two of 43 patients were weaned off bypass and were balloon assisted for 12 to 96 hours postoperatively; 25 patients were discharged (58 per cent). In Subgroup A, 14 of 23 (60 per cent) and, in Subgroup B, 9 of 20 (45 per cent) were long-term survivors. Based on these findings, 45 patients were operated upon between June, 1974, and December, 1975, with elective use of 1ABP and were assessed by serial hemodynamic studies. Sixteen had severe preoperative left ventricular dysfunction similar to Subgroup A and 29 had moderate dysfunction in combination with pathology similar to Subgroup B. Fifteen of these patients were hemodynamically unstable at time of arrival in the operating room; 1ABP was inserted under local anesthesia. Thirty-nine patients (87 per cent) were weaned off bypass and were hospital survivors. In Subgroup A, 13 of 16 (81 per cent) and, in Group B, 21 of 29 (72 per cent) were long-term survivors. Criteria for elective use of 1ABP in cardiac surgery should include severe preoperative left ventricular dysfunction or a combination of moderate dysfunction with coronary or valvular pathology. Elective 1ABP improves the survival with trivial iatrogenic morbidity.     

Aortic aneurysm complicated with coarctation of the aorta and Turner syndrome

A 23-year-old female with Turner syndrome and horse-shoe kidney underwent the operation of the coarctation of the aorta associated with the thoracic aortic aneurysm. The aortic aneurysm was located between the left carotid artery and the coarctation of the aorta, and the subclavian artery which was branched away from the aortic aneurysm was also aneurysmal. Aneurysmectomies and the reconstruction of the descending thoracic aorta and the left subclavian artery were performed with knitted Dacron grafts under assisting of the left atriodescending thoracic aortic bypass with Bio-pump. The disease was rare and such a case was not reported previously.     

Arterial prosthesis of microporous expanded polytetrafluoroethylene for construction of aorta-pulmonary shunts

A new arterial prosthesis made of polytetrafluoroethylene (OTFE) was evaluated in 10 infants with complex cyanotic congenital heart disease. All grafts used were 4 mm. in diameter and varied in length from 0.8 to 6 cm. The grafts were anastomosed to the main pulmonary artery or its bifurcation in 8 infants and to the right and left pulmonary arteries in one each. There were two early deaths, one of which was related to shunt failure. The advantages of a shunt to the main pulmonary artery are obvious, and the intraoperative procedure is facilitated with the prosthesis. Follow-up averages 9 months in the 8 survivors, and the patients have nearly doubled their preoperative weight. A shunt murmur is present in each case and the children have mild-to-moderate cyanosis at rest. Repeat aortograms in 2 patients, 8 and 10 months postoperatively, show a smooth graft without luminal narrowing. The aortic oxygen saturations were 73 per cent. The PTFE graft and/or anastomoses will not grow with the growth of the child and therefore may not accommodate growth by increased flow. This may prove to be a limiting factor in its long-term use in fants. We reserve the use of these grafts for infants with complex cyanotic defects undergoing emergency surgery or in older children in whom a conventional shunt is not possible or a previous shunt has failed.     

Use of intra-aortic balloon pumping (IABP) in clinical cardiac surgery and management of patients with IABP

One hundred thirty eight patients were reviewed which required IABP assist. Sixty nine (84 per cent) of 82 patients who had been able to come off cardiopulmonary bypass despite increasing pharmacologic support survived operation and 56 patients (68 per cent) discharged hospital. Twenty three (75 per cent) of 31 patients who took for elective coronary artery surgery as extremely high risk because of extensive three vessel coronary artery disease and severely compromised left ventricular function discharged hospital. In summary, hospital death was 35 per cent, late death 12 per cent and long term survivors 54 per cent. Severe complication concerned with inserting balloon catheter occurred in two cases (1.4 per cent) which were abdominal aortic dissection and laceration of iliac artery. At the present time, the primary indication for IABP is in assistance of the open heart surgical patient. Thre are three important factors in successfully managing the patients with IABP. First, begin IABP assist as soon as possible if indicated. Second, keep an adequate circulating volume with mean left atrial pressure being maintained around 20 mmHg and cardiac index at 2.1 L/min./M or greater. Third, improve the peripheral vascular circulation, which might need peripheral vasodilator.     

Management of failed and infected axillofemoral grafts

PURPOSE: The purpose of this study was to review the treatment of patients with failed or infected axillofemoral bypass grafts and to determine the efficacy of remedial procedures in maintaining graft patency and limb preservation. METHODS: Thirty-four patients with 37 failed or infected axillofemoral grafts were retrospectively reviewed. In nine cases there was no attempt at revascularization, and in the remaining 28 cases, a total of 52 remedial procedures was performed. Nine were performed in patients with graft infection and 43 in patients with graft thrombosis. In patients with axillofemoral graft failure, 21 thrombectomies, 13 graft revisions, and 9 secondary reconstructions were performed. Eighty-eight percent of patients were monitored at least 2 years or until graft failure. RESULTS: Eight of nine patients receiving no remedial procedure required major amputation. The limb salvage rate was 64% +/- 11% at 30 months in the 25 patients undergoing remedial procedures. Twenty-eight percent of failed axillofemoral grafts remained patent at 2 years after initial failure with single or multiple thrombectomies or revisions. Life-table primary patency after secondary reconstructions (81% +/- 10.9% at 24 months) was significantly better than after thrombectomy alone (10% +/- 4.2% at 24 months) or graft revision (16% +/- 10.6% at 24 months) by log-rank test (p < 0.001 and p < 0.005, respectively). Patients undergoing reconstruction with descending thoracic aorta to femoral artery bypass had an 89% +/- 11% patency rate at 24 months. Graft infection resulted in a perioperative mortality rate of 22% and amputation in 57% of survivors. CONCLUSION: Axillofemoral graft failure most often results in limb loss without remedial procedures. Thrombectomy and revision procedures had poor long-term patency rates and salvaged only a minority of grafts despite multiple procedures. Reconstruction by use of an alternate source of inflow such as the descending thoracic aorta resulted in better long-term patency rates in patients well enough to tolerate a major reoperative procedure.     

Ketamine for pediatric cardiac anesthesia

Eighty-five patients ranging from 12 h to 7 years of age were included in this study. In the first group 35 cases received ketamine, gallamine and oxygen for surgery on the great vessels. Ketamine provided satisfactory analgesia and amnesia. Heart rate did not change significantly. Gallamine gave additional safety in the prevention of bradycardia. One hundred per cent oxygen increased oxygen saturation and made more oxygen available for the tissues. The combination secured favorable conditions even in cases of sevre right to left shunt. Seven patients developed some degree of bradycardia, requiring treatment. All but one responded to epinephrime infusion. The one who did not improve died on the table. There were 6 additional deaths during the first 48 postoperative hours. Fifty infants and children received pentobarbital and morphine premedication and ketamine, pancuronium, nitrous-oxide oxygen anesthesia for open heart surgery. Cardiovascular stability with good operating conditions characterized the course of anesthesia. The increase in systolic and diastolic blood pressures and heart rate was small after induction. Further changes in these parameters during anesthesia were statistically insignificant. Perfusion pressure during cardio-pulmonary bypass was well maintained. The addition of 50 per cent nitrous oxide to inhaled oxygen significantly potentiated the duration of hypnosis and analgesia proved by ketamine. Mechanical ventilation was facilitated in both groups by the analgesia extending well into the postoperative period. There were 6 deaths in the first 48 postoperative hours in this group. The state of consciousness at the end of anesthesia and postoperative conditions of all 85 patients were comparable with that found with other agents. The techniques described provided suitable alternatives to the anesthetic management pediatric cardiac surgery.     

Angiographic 20-year follow-up of 61 consecutive patients with internal thoracic artery grafts

OBJECTIVE: To assess the behavior of internal thoracic artery (ITA) grafts versus venous grafts in repeated angiograms up to 20 years. SUMMARY BACKGROUND DATA: Use of ITA grafts to bypass left anterior descending artery stenosis has been shown to be associated with improved survival in patients undergoing coronary artery bypass grafting. METHODS: Sixty-one consecutive patients who received one or two ITA grafts and who underwent surgery from Oct. 5, 1971, to Dec. 18, 1973, in Helsinki University Central Hospital, Finland, were included in this prospective follow-up series. Fifty-six of the patients (92%) also received at least one venous graft. The number of distal anastomoses was 157, of which 47.7% (75) were performed with ITA grafts. The median age of the patients was 47.7 years (range 30.0 to 63.1), and 85% (52) were men. RESULTS: After 20 years of follow-up, 18/20 (90%) of the survivors underwent angiography; the patency rate was 88.9% for ITA grafts and 47.8% for venous grafts. Cumulative graft patency at 20 years, using all the information obtained from repeated angiographic examinations and autopsies, was also calculated to eliminate selection bias. The cumulative 20-year patency rate was 81% for ITA-left anterior descending artery anastomoses, 53.8% for venous graft-right coronary artery anastomoses, and 48.5% for venous graft-left circumflex artery anastomoses. In paired comparisons between anastomoses, the patency time of the ITA-left anterior descending artery anastomoses was on average 2.8 years longer than the venous graft-left circumflex artery patency time and 2.6 years longer than the venous graft-right coronary artery. CONCLUSIONS: Internal thoracic artery grafts, especially in left anterior descending artery anastomoses, should be considered as a primary solution in coronary artery bypass grafting surgery in patients with >10 years of life expectancy; if venous grafting is preferred, further evidence is needed.     

Coarctation of the thoracoabdominal aorta

Coarctation of the thoracic or abdominal aorta often is associated with reduced perfusion of one or both kidneys, resulting in severe renovascular hypertension, which significantly influences the spontaneous course of these patients. Fourteen of 15 patients who were operated upon between 1983 and 1996 suffered from arterial hypertension. Thirteen patients had ischemia of one or both kidneys resulting from renal artery stenosis or stenosis of the descending or visceral aorta. Because of a hemodynamically significant stenosis the aorta was reconstructed in 11 patients by interposition graft, bypass, or patchplasty. Concerned renal or visceral arteries were reconstructed by bypass/interposition graft, patchplasty, or reimplantation. One patient died, presumably from septic bleeding, 3 weeks post operatively. There was a cure of hypertension in 3 and an improvement in 6 patients. In the individual patient hypertension could be cured more often if the diagnosis of coarctation were established early.     

The gastroepiploic artery graft in coronary artery bypass surgery

From March 1986 to October 1989, 91 patients underwent CABG using the right gastroepiploic artery (GEA) at Osaka Medical College and Mitsui Memorial Hospital. Including 14 females, the mean age was 57.9 years old ranged from 34 to 73 years old. Triple vessel disease and left main disease occupied over 90% of the patients. There were 5 emergency operations and 6 reoperations. Associated serious diseases were; renal failure with hemodialysis in 2 pts., familial hyperlipidemia in 5 pts., severe atherosclerotic ascending aorta in 8 pts., arteriosclerosis obliterance in 3 pts., and each one of abdominal aortic aneurysm and idiopathic thrombocytopenic purpura. The internal thoracic artery (ITA) graft was concomitantly utilized in 96% of the patients. Single ITA in 60 pts., double ITA in 23 pts. and sequential ITA in 5 patients. Saphenous vein graft was used in 58 patients and remaining 33 patients were operated without leg wound. The mean number of distal anastomoses was 3.3 ranged from 1 to 5, and the mean number of arterial grafts was 2.5 ranged from 1 to 4. The mean aortic cross clamp time and cardiopulmonary bypass time was 62.8 minutes and 113.6 minutes, respectively. Sites of GEA anastomosis were; 4 anterior descending, 3 diagonal, 11 circumflex and 73 right coronary arteries. There were 86 in situ grafts mostly for the right coronary arteries, and remaining 5 GEAs were used as a free graft to bypass the left coronary arteries. On the contrary, ITA was used to bypass the left coronary artery system preferentially. There was 3 combined procedures; splenectomy, abdominal aorta replacement, and ascending aorta to bifemoral artery bypass in each one patients. Three patients including one emergency case died within 30 days after surgery. Two were cardiac and one was renal failure. Other 2 patients died of stroke at late period. New Q wave infarction was noted in 2 patients. Relief of angina was obtained in 98% of survivors. The patency rate of the GEA graft was 97% in 61 grafts restudied within 6 postoperative months, which was identical with that of the ITA graft, that is 97% of 76 grafts. In conclusion, the GEA has several advantages as a coronary artery bypass graft such as similarity in size to the coronary artery, rare arteriosclerosis, feasibility of in situ graft, and no gastric complication. Its flow capacity is studying now and favourable results are being obtained. The final problem, its long term patency, will be resolved in future. GEA is a promising conduit for the coronary bypass surgery.     

Age specific prostate specific antigen reference ranges: population specific

BACKGROUND: Anastomosis of the left internal thoracic artery to the left anterior descending artery without sternotomy and without cardiopulmonary bypass is a standard approach in minimally invasive coronary artery bypass grafting. To expand the indications for minimally invasive coronary artery bypass grafting from one-vessel disease to two-vessel disease, we began to perform anastomosis of the right gastroepiploic artery (RGEA) to the right coronary artery (RCA). METHODS: From February to November 1996, an RGEA graft was used in 25 of the 100 patients who underwent minimally invasive coronary artery bypass grafting at our clinic. Eleven of the patients had only RCA disease and 14 had both RCA and left anterior descending artery disease. One of the operations was a redo coronary artery bypass grafting. The RGEA was anastomosed to the RCA through a laparotomy incision and the left internal thoracic artery was anastomosed to the left anterior descending artery through a left anterior thoracotomy. In 5 patients, the RGEA was lengthened by venous grafting. RESULTS: All patients underwent angiography after operation; 82.6% of the RGEA grafts and all the left internal thoracic artery grafts were functioning well. In three of the four nonvisualized RGEA grafts, the percentage of proximal stenosis of the RCA seen on postoperative angiography was not critical (40%, 50%, and 50%, respectively), allowing significant competitive flow through the native bypassed RCA. The patency of all the RGEA grafts without competitive flow was 95%, with a 95% confidence interval of 75.1% to 99.9%. CONCLUSIONS: The indications for minimally invasive coronary artery bypass grafting could be extended to primary operations in patients with left anterior descending artery and RCA lesions by using both the left internal thoracic artery and the RGEA.