Throughout its 30-year history, the right gastroepiploic artery (GEA) has been useful for in situ grafts in coronary artery bypass grafting (CABG). The early graft patency rate is high, and the late patency rate has improved by using the skeletonized GEA graft and proper target selection, which involves having a target coronary artery with a tight >90% stenosis. Total arterial revascularization with the internal thoracic artery and GEA grafts is an option for achieving better outcomes from CABG procedures.
Constriction, Pathologic ; Coronary Artery Bypass* ; Coronary Artery Disease ; Coronary Vessels* ; Gastroepiploic Artery* ; Mammary Arteries ; Myocardial Ischemia ; Myocardial Revascularization ; Skeleton ; Transplants*

We report a 68 old male, who underwent coronary artery bypass using left internal mammary artery, right gastroepiploic artery, and saphenous vein graft and ascending aorta to bifemoral bypass using polytetrafluoroethylene graft, under the diagnosis of severe three coronary arterial disease and bilateral occlusive illiac arterial disease. The procedure of ascending aorta to bifemoral bypass is considered to have the advantage compared with traditional femoral by passes especially combined coronary and femoral arterial revascularization is needed.

A chronic traumatic thoracic aortic aneurysm, 19 years after a traffic accident was successfully treated. A 34-year-old man was admitted because of chest discomfort. An upper GI examination was performed and an esophageal submembranous tumor was suspected. However, a chest CT examination showed a thoracic descending aortic aneurysm, the maximum size of which was 7.5cm×5.5cm. The final diagnosis was chronic traumatic thoracic aortic aneurysm. Generally most cases of chronic traumatic thoracic aortic aneurysm have no symptoms for a long time after an accident. However, some have reported that the development of an aneurysm is due to not receiving treatment. We performed graft replacement using the temporary bypass method because it was an easy technique and required less heparinization. Chronic thoracic aortic aneurysms have lower risk of bleeding during the operation than acute cases. For chronic cases which have stable hemodynamics, adjunctive methods (e. g., partial extracorporeal bypass, left ventricular bypass and temporary bypass) may facilitate a safe operation.

Three cases of LMCAP for the isolated LMCA stenosis were presentd. In two cases of the proximal LMCA stenosis, the connective tissue between the ascending aorta and the main pulmonary artery was prepared to detect the LMCA. From the left lateral wall of the ascending aorta to the anterior wall of the LMCA over the stenotic lesion was excised and the saphenous vein patch was sutured (anterior approach). In the third case, because the stenosis was locarized at the distal LMCA, the patch angioplasty using the saphenous vein was performed by direct opening of the distal LMCA accessed from the left lateral side of the main pulmonary artery without aortotomy (lateral approach). Ultrasonic cuser was quite useful to isolate the LMCA. LA-LV vent was indispensable to obtain the non-blood clean operation field. All three cases showed the successful enlargement of LMCA at the postopeorative coronary angiography.

Our experience with 13 patients (mean age 52, range 35-71 years) undergoing pericardiectomy at Mitsui Memorial Hospital in the 13 years (from 1977 to 1990) has examined with clinical features and M-mode echocardiographic study. Preoperatively, the patients were either in N. Y. H. A. Functional Class III (11 cases), or Class IV (2 cases). Median sternotomy without using cardiopulmonary bypass was employed in all cases. The area of the right ventricle, atria, cavae, pulmonary veins and left ventricle where can be reached without cardiopulmonary bypass or other hemodynamic support were decorticated completely, and the posterior portion of the left ventricle were not decorticated partially. Intraoperative hemodynamic responses were observed between before and after pericardiectomy monitored by Swan-Ganz catheter; central venous pressure (CVP) were changed from 21.3±5.6 to 13.6±4.0cmH₂O, pulmonary artery diastolic pressure (PADP) were changed from 19.8±5.5 to 11.3±6.6mmHg, cardiac index (CI) were changed 2.14±1.34 to 3.16±1.73l/min/m². There were no early deaths and no late heart complicated deaths. There were 2 cases died, one for advanced gastric carcinoma and another for wide cerebral infarction whthin 3 years from pericardiectomy. M-mode echocardiographic study that were examined between preoperative and late postoperative periods (mean follow-up time 51 months) showed effective recovery in cardiac function; left ventricular end-diastolic volume index (LVEDVI) were from 34.3±12.1 to 39.5±14.5ml/m², left ventricular end-systolic volume index (LVESVI) were from 17.2±7.8 to 13.1±6.7ml/m², stroke index (SI) were from 17.1±7.3 to 26.6±12.5ml/m², ejection fraction (EF) were from 45.1±19.2 to 61.2±22.5%, mean velocity of circumferential fiber shortening (mean Vcf) were from 0.80±0.35 to 1.13±0.53circ/sec. All the patients showed functional improvement; 9 are in N. Y. H. A. Functional Class I, and 4 are in Class II. These findings would be permitted this procedure with median sternotomy for chronic constrictive pericarditis as one of a safety and effective method conventionally.

The authors employed a modified CABG procedure to avoid cerebral infarction in cases of calcified ascending aorta. Among 348 cases of CABG surgery, we used the modified procedure in 14 cases (4%). The mean age was 66. Four patients had a history of previous stroke and one patient had arteriosclerosis obliterans. Our strategy is, (1) use femoral or aortic arch cannulation for cardiopulmonary bypass (CPB), (2) maximal use of in-situ arterial graft, (3) graft-coronary anastomosis under ventricular fibrillation (Vf) without aortic cross clamp, (4) proximal anastomosis of saphenous vein graft (SV), if used, was made at the arterial graft, otherwise direct anastomosis to the aorta was made under circulatory arrest. The internal thoracic artery (ITA) was used in 18 cases and the gastroepiploic artery (GEA) was used in 8 cases, SV was used in 4 cases. The mean Vf time was 48min and mean CPB time was 94min. The peak CPK was 805U and the peak CPK-MB was 52U. There was no significant difference between modified and conventional procedures in terms of operation time and myocardial protection. No cerebrovascular complication was noted with the modified procedure. In conclusion, the modified technique is safe for atherosclerotic-ascending aorta in CABG.

A 59-year-old man, who had received graft replacement for the “inflammatory” abdominal aortic aneurysm two years previously was admitted to our hospital because of preshock caused by intermittent intestinal hemorrhage. Gastrointestinal endoscopy revealed an ulcer at the 3rd portion of the duodenum. As aortoenteric fistula was diagnosed and he underwent an emergency operation. After initial axillo-bifemoral bypass grafting, the aortic graft was removed and the aortic stump was closed directly. The duodenal rent was closed by Albert-Lembert suture, He survived the operation and was discharged. We suggest that extra-anatomic bypass is safer than in situ graft replacement in patients with secondary aortoenteric fistula after operation for “inflammatory” abdominal aortic aneurysm, because adjacent organs adhere firmly to the proximal suture line in such cases.