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Techniques in Skeletonized GEA Harvest
Tohru Asai, Tomoaki Suzuki, Takeshi Kinoshita, Susumu Fujino, Reo Sakakura, Shinya Terada.
Shiga University of Medical Science, Otsu, Japan.

OBJECTIVE: Use of arterial graft conduits is recommended for coronary artery bypass grafting, however a gastroepiploic artery (GEA) is underused. We previously reported excellent long-term patency (90.4% in 8 years) and good clinical outcomes using two skeletonized ITAs and a skeletonized GEA. The video demonstrates pearls and pitfalls in technique of harvesting the skeletonized GEA. METHODS: A sternotomy is extended about 5 cm caudally. Prior to harvesting ITAs, the peritoneal cavity is opened by cutting down the diaphragm vertically instead of a large midline abdominal incision. The GEA is inspected and palpated to confirm it as a suitable conduit. After skeletonizing ITAs, the skeletonized GEA is harvested using the Harmonic Scalpel with the coagulating shears tip. The first step is to pass vessel loops under the GEA at 5-cm intervals. The anterior layer of the omentum is incised, And only the artery is encircled with the vessel loops. This is carried out through the entire length from the level of the pylorus. The second step is to unroof the tissue surrounding the GEA. The anterior layer of the omentum is divided between the vessel loops. The tissue pad jaw of the shears is inserted through the soft tissue in such a way that the GEA trunk is protected from heat energy during use of the Harmonic Scalpel. GEA is then exposed throughout its entire length. The next step is to seal and sever all the branches together. The whole surrounding tissues are detached by coagulating shears approximately 2 mm away from the GEA. The whole skeletonization of the GEA takes about 10 min. We exclusively use in-situ skeletonized GEA for RCA or distal circumflex with severe stenosis. RESULTS: We have performed 687 isolated coronary artery bypasses with skeletonized GEA since January 2002. It is 53.8% (687/1277) of our whole series. Early graft patency was 98% and there was no abdominal complication. CONCLUSIONS: Skeletonized GEAs can be securely harvested using Harmonic Scalpel with limited incisional extension. When it is grafted to inferior wall target vessels with greater than 90% stenosis, clinical outcomes and patency rate are excellent.

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Endorsed by:
The Society of Thoracic Surgeons

Co-sponsored by:
Association of Physician Assistants in Cardiovascular Surgery (APACVS) The International Society for Minimally Invasive Cardiothoracic Surgery Japanese Association for Coronary Artery Surgery
Brazilian Society of Cardiovascular Surgery Fu-Wai Hospital of Beijing Indian Association of Cardiovascular-Thoracic Surgeons
Society for Cardiothoracic Surgery in Great Britain & Ireland