Coronary artery surgery with the right gastroepiploic artery: optimal routing sites through the diaphragm.

A possible problem in coronary artery surgery with the right gastroepiploic artery (GEA) is kinking of the GEA at the tunnel through the diaphragm. This study was performed to find the best routes through the diaphragm to different coronary branches. The freed gastroepiploic pedicle was filled with contrast and routed posterior to the pylorus. The right coronary artery (RCA), the left anterior descending artery (LAD), and the largest marginal branch were also filled with contrast. One diaphragmatic incision was made close to the vena cava (paracaval), another anterior to the esophagus (ante-esophageal) and a third close to the diaphragmatic vein. By each route the GEA was directed towards each coronary artery. In each position the occurrence of kinks and the length necessary to reach the coronary artery was studied. The most preferable combinations of diaphragmatic incision and grafting site were the paracaval incision for the RCA system and the ante-esophageal incision for marginal branches.