From the Thoraxcenter, University Hospital Groningen, the Netherlands.
Correspondence to Jan G. Grandjean, MD, PhD, Department of Cardiothoracic Surgery, University Hospital of Groningen, Hanzeplein 1, 9713 EZ Groningen, the Netherlands. E-mail J.G.Grandjean{at}thorax.azg.nl
Methods and Results—We reviewed a group of 256 patients
with 3-vessel disease who received the right gastroepiploic artery
together with both internal thoracic arteries (ITAs). Vein grafts were
not used in these patients. The patients were monitored for up to 7
years (mean, 51±15 months). Seven-year actuarial survival was 91.1%.
The cumulative probability of event-free survival for myocardial
infarction, reintervention, and angina pectoris at 7 years was 97.3%,
95.4%, and 85.4%, respectively.
Conclusions—We conclude that concomitant use of the
gastroepiploic artery with both ITAs results in low mortality and a low
incidence of myocardial infarction and reintervention at follow-up.
Most interestingly, we found 85.4% freedom from angina pectoris after
7 years, which is considerably lower than the results of studies in
which vein grafts, single ITA grafts, or double ITA grafts are used.
These results strongly support the use of both ITAs and the right
gastroepiploic artery for bypass grafting in patients with 3-vessel
disease.
All data were updated in the beginning of 1997, and the common closing
date was April 30, 1997. Clinical information about survival and
subsequent cardiac events was obtained through interviews by medically
trained personnel and examination by the patient's own cardiologist.
In the case of cardiac events, the patient's own physicians were asked
for more detailed information.
The following clinical events were analyzed: mortality (from
any cause, including in-hospital mortality), myocardial infarction
(including perioperative infarction), cardiac
reoperations (CABG and PTCA), and the recurrence of angina
pectoris (graded according to the New York Heart Association scale).
The actuarial survival was calculated according to the Kaplan-Meier
method.
Mortality
Morbidity
Eleven patients underwent a reintervention procedure. Two patients had
to undergo a repeat CABG (a few hours after their operation), and 9 had
to undergo PTCA. The actuarial freedom from reintervention at 7 years
after the operation was 95.4% (Figure
After leaving the hospital, 28 patients experienced a return of angina
pectoris. Eighteen were in NYHA class II, and 10 in NYHA class III.
Seven-year angina-free cardiac survival was 85.4% (Figure
However, venous grafts (in combination with 1 or 2 ITA grafts) are
still used in the majority of patients. A reasonable alternative for
the saphenous vein graft in conjunction with both ITAs is the right
GEA. With the GEA, myocardial revascularization can
be achieved with the use of arterial grafts only, even in
patients with 3-vessel disease.
We restudied a group of 256 patients suffering 3-vessel disease who
underwent CABG with arterial grafts only (both ITAs and the
GEA). Mean postoperative follow-up was 51±15 months (up to 84 months),
which at present is the longest follow-up of the use of the GEA
graft in combination with 2 ITA grafts as yet reported. We compared our
results with those of clinical studies in which patients were operated
on with vein grafts and/or ITA grafts and in which the actuarial
survival was calculated.
Mortality
Morbidity
Reintervention
Angina Pectoris
Data published on results in patients with coronary
revascularization with vein grafts, single ITA
grafts, and double ITA grafts are in most instances difficult to
compare because of differences in inclusion and exclusion criteria. A
limitation of the study is that we compared our group of patients with
historical control subjects. Furthermore, follow-up is still too short
to draw definitive conclusions. Nevertheless, if we allow comparisons
in this early stage, we demonstrated that mortality,
myocardial-infarction, and reintervention rates in our patients with
3-vessel disease were at least comparable to the results of other
studies. Moreover, our results indicate a lower recurrence of
angina pectoris after 7 years of follow-up.
Received November 11, 1997;
revision received February 20, 1998;
accepted March 5, 1998.
2.
Berreklouw E, Schonberger JP, Bavinck JH, Verwaal VJ,
Koldwijn EL, van der Linden F, van der Tweel I, Bredee JJ. Similar
hospital morbidity with the use of one or two internal thoracic
arteries. Ann Thorac Surg. 1994;57:1564–1572.[Abstract]
3.
Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Coormastic
M, Williams GW, Golding LAR, Gill CC, Taylor PC, Sheldon WC, Proudfit
WL. Influence of the internal mammary artery graft on 10-year survival
and other cardiac events. N Engl J Med. 1986;314:1–6.[Abstract]
4.
Cameron AA, Green GE, Brongno DA, Thornton J.
Internal thoracic artery grafts: 20-year clinical follow-up.
J Am Coll Cardiol. 1995;25:188–192.[Abstract]
5.
Manapat AE, McCarthy PM, Lytle BW, Taylor PC,
Loop FD, Stewart RW, Rosenkranz ER, Miller D, Cosgrove DM.
Gastroepiploic and inferior epigastric arteries for
coronary artery bypass: early results and evolving
applications. Circulation. 1994;90(suppl II):II-144-II-147.
6.
Grandjean JG, Boonstra PW, Den Heyer P, Ebels T.
Arterial revascularization with the
right gastroepiploic artery and internal mammary arteries in 300
patients. J Thorac Cardiovasc Surg. 1994;107:1309–1316.
7.
Suma H, Amano A, Horii T, Kigawa I, Fukuda S,
Wanibuchi Y. Gastroepiploic artery graft in 400 patients. Eur
J Cardiothorac Surg. 1996;106:6–11.
8.
Grandjean JG, Voors AA, Boonstra PW, Den Heyer
P, Ebels T. Exclusive use of arterial grafts in
coronary artery bypass operations for three-vessel disease: use
of both thoracic arteries and the gastroepiploic artery in 256
consecutive patients. J Thorac Cardiovasc Surg. 1996;112:935–942.
9.
Lytle BW, Taylor PC, Simpfendorf C, Kramer JR,
Ratliff NB, Goormastic M, Cosgrove DM. Vein graft disease: the clinical
impact of stenoses in saphenous vein bypass grafts to
coronary arteries. J Thorac Cardiovasc Surg. 1992;103:831–840.[Abstract]
10.
Mills NT, Everson CT. Vein graft failure. Curr
Opin Cardiol. 1995;10:562–568.[Medline]
[Order article via Infotrieve]
11.
Fitzgibbon GM, Kafka HP, Leach AJ, Keon WJ, Hooper GD,
Burton JR. Coronary bypass graft fate and patient outcome:
angiographic follow-up of 5065 grafts related to survival and
reoperation in 1388 patients during 25 years. J Am Coll
Cardiol. 1996;38:616–626.
12.
Loop FD. A 20-year experience in coronary
artery reoperation. Eur Heart J. 1989;10:78–84.
13.
Bourassa MG, Fisher LD, Campeau L, Gillespie MG,
McConney M, Lesperance CJ. Long-term fate of bypass grafts: the
Coronary Artery Surgery Study (CASS) and Montreal Institute
experiences. Circulation. 1985;72(suppl V):V-71–V-78.
14.
Van Brussel BL, Plokker HWT, Ernst SMPG, Ernst NM,
Knaepen PJJ, Koomen EM, Tijssen JGP, Vermeulen FEE, Voors AA. Venous
coronary artery bypass study: a 15-year follow-up study.
Circulation. 1993;88(part 2):II-87–II-92.
15.
Sergeant P, Lesaffre E, Flameng W, Suy R, Blackstone E.
The return of clinically evident ischemia after
coronary artery bypass grafting. Eur J Cardiothorac
Surg. 1991;5:337–457.
16.
Pick AW, Orszulak TA, Anderson BJ, Schaff HV. Single
versus bilateral internal mammary artery grafts: 10-year outcome
analysis. Ann Thorac Surg. 1997;64:599–605.Use
of the gastroepiploic artery with both internal thoracic arteries for
total arterial revascularization has
high actuarial survival rates and a high cumulative probability of
event-free survival for myocardial infarction, reintervention, and
especially angina pectoris at 7 years after the operation.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Low Recurrence of Angina Pectoris After Coronary Artery Bypass Graft Surgery With Bilateral Internal Thoracic and Right Gastroepiploic Arteries
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—In the past 10 years,
there has been a trend to use more arterial grafts instead
of vein grafts for coronary artery bypass graft surgery.
Although there are many reports on the short- and mid-term follow-up of
patients who underwent arterial
revascularization with 1 or 2 arteries, little has
been reported on the follow-up of patients with 3-vessel disease who
received 3 arteries.
Key Words: angina • arteries • bypass • follow-up studies • revascularization
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
The use of single as
well as double ITA grafts instead of vein grafts in CABG has been
demonstrated through the years to improve survival and to reduce the
recurrence of myocardial ischemia and the occurrence of
late myocardial infarction without a significant increase in
perioperative morbidity or
mortality.1 2 3 4 Therefore, the current trend in
CABG is toward completely arterial
revascularization, even in patients with 3-vessel
disease. However, in most patients with 3-vessel disease, the two ITAs
do not provide enough graft material to revascularize the entire
myocardium. This encouraged the use of the right GEA as a
pedicled arterial graft for myocardial
revascularization. At present, only short-term
results of use of the GEA for bypass grafting are well
documented.5 6 7 8 Recently, we described
perioperative morbidity and mortality of a group of 256
patients with 3-vessel disease who underwent myocardial
revascularization with exclusive use of both ITAs
and the GEA. Venous grafts were not used.8 These
results have now been updated. Therefore, the aim of the present
study is to describe the 7-year clinical follow-up of this group of
patients.
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Between September 1989 and September 1994, 3720 patients were
operated on for coronary artery disease in our institution.
Revascularization of all 3 vessels was performed in
1495 patients. In this group of patients, the GEA in combination with 2
ITAs was used in 256 patients (17%), who then composed the study
population. Baseline characteristics of these patients are shown in
Table 1
.
View this table:
[in a new window]
Table 1. Baseline Patient
Characteristics
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
No patient was lost during follow-up. Mean postoperative follow-up
was 51±15 months (up to 84 months).
During follow-up, a total of 12 patients died (4.7%). Four
patients died in the hospital of in-hospital complications as described
in our previous report.8 One patient died of
brain infarction, 1 of a myocardial infarction caused by embolization
of atheromatous material from the aorta, 1 of an
anterior infarction after the left anterior descending branch was not
found, and 1 of cardiac failure. The other 8 patients died 25, 26, 28,
38, 44, 52, 63, and 68 months, respectively, after the operation. Four
patients died of noncardiovascular causes (2 of lung
carcinoma, 1 of colon carcinoma, 1 of a temporal subdural hematoma).
Four patients died of a cardiovascular cause (2 of
cardiac failure, 1 of ventricular fibrillation, 1 of
endocarditis). Seven-year actuarial survival (including in-hospital
death and death from a noncardiovascular cause) for
this group of patients was 91.1% (Figure, panel A).
View larger version (25K):
[in a new window]
Figure 1. Actuarial curves estimated according to the
Kaplan-Meier method. A represents actuarial survival curve. In-hospital
mortality was included in calculation. The 7-year actuarial survival
was 91.1%. B represents actuarial freedom from myocardial infarction.
Perioperative infarctions were included in calculation. The 7-year
actuarial freedom from myocardial infarction was 97.3%. C shows
actuarial freedom from reintervention (repeat CABG and PTCA). Note, we
included 2 in-hospital reoperations in our calculation. Actuarial
freedom from reintervention at 7 years after operation was 95.4%. D
shows actuarial freedom from angina pectoris after operation. The
7-year angina-free cardiac survival was 85.4%.
In-hospital infarction occurred in 5
patients.8 After discharge from hospital, 2
patients suffered a myocardial infarction (1 anteroseptal and 1
inferior), at 8 and 20 months, respectively, after the
operation. Seven-year infarct-free cardiac survival for this group of
patients (including 5 in-hospital infarctions) was 97.3% (Figure
,
panel B). , panel C). , panel
D).
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
Arterial grafts are preferred to venous grafts
for CABG, because long-term patency of venous grafts is poor, with
consequent recurrent angina pectoris and subsequent cardiac
events.9 10 11 12 In contrast, excellent long-term
patency and better patient outcomes have been demonstrated for ITA
grafts in several series.1 2 3 4 The improved
survival with ITA grafts is due to improved patency rates of these
grafts, which, if they are patent immediately after surgery, usually
remain patent, whereas vein grafts exhibit progressive
atherosclerosis.13
Actuarial 7-year survival in our study group was 91.1%. This is a
satisfactory outcome compared with studies in which vein grafts, single
ITA grafts, or double ITA grafts are used, especially considering that
we studied only patients with 3-vessel disease and we included
in-hospital mortality in the calculation of the actuarial 7-year
survival (Table 2).
View this table:
[in a new window]
Table 2. Overview of Published Reports on Actuarial Survival
and Actuarial Probability of Remaining Free From Myocardial Infarction,
Reintervention (Repeat CABG or Coronary Balloon Angioplasty), and
Angina Pectoris 7 Years After Primary
Operation
Myocardial Infarction
Seven-year actuarial freedom from myocardial infarction in our
study group was 97.3%. Despite the inclusion of 5 in-hospital
infarctions in our calculation of the actuarial freedom from myocardial
infarction, the percentage of patients in our study group remaining
free from myocardial infarction during follow-up is higher than in the
comparable studies (Table 2).
The 7-year actuarial probability of remaining free from
reintervention after coronary bypass in our study (95.4%) is
comparable to that in other studies (Table 2). However, again it should
be noted that, in contrast to the other studies, we included 2
in-hospital reoperations.
Actuarial freedom from angina pectoris after 7 years was 85.4%,
which is considerably lower than in the studies in which vein grafts,
single ITA grafts, and double ITA grafts were used (Table 2). Because
all patients in our study group were explicitly asked about anginal
complaints, we firmly believe that we have not underreported the
incidence of angina.
Selected Abbreviations and Acronyms
CABG
=
coronary artery bypass graft surgery
GEA
=
gastroepiploic artery
ITA
=
internal thoracic artery
PTCA
=
percutaneous transluminal coronary
angioplasty
Acknowledgments
We thank the Jan Kornelis de Cock Stichting for financial
support that made this study possible and Reinoud Brouwer, Leonie de
Noo, Carsten Mellema, Robbert Mollema, and Bas Wallis de Vries for
helping to take the yearly patient interviews.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
1.
Fiore AC, Naunheim KS, Dean P, Kaiser GC,
Pennington G, Willman VL, McBride LR, Barner HB. Results of the
internal thoracic artery grafting over 15 years: single versus double
grafts. Ann Thorac Surg. 1990;49:202–208.[Abstract]
This article has been cited by other articles:
 |
|
 |
|
  M. Di Mauro, M. Contini, A. L. Iaco, A. Bivona, M. Gagliardi, E. Varone, P. Bosco, and A. M. Calafiore Bilateral internal thoracic artery on the left side: A propensity score-matched study of impact of the third conduit on the right side J. Thorac. Cardiovasc. Surg., April 1, 2009; 137(4): 869 - 874. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. S. Kim, J. Lee, Y. T. Lee, K. Sung, J.-H. Yang, T.-G. Jun, and P. W. Park Total Arterial Revascularization in Triple-Vessel Disease With Off-Pump and Aortic No-Touch Technique Ann. Thorac. Surg., December 1, 2008; 86(6): 1861 - 1865. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. J.G.M. Veeger, G. F. Panday, A. A. Voors, J. G. Grandjean, J. van der Meer, and P. W. Boonstra Excellent Long-Term Clinical Outcome After Coronary Artery Bypass Surgery Using Three Pedicled Arterial Grafts in Patients With Three-Vessel Disease Ann. Thorac. Surg., February 1, 2008; 85(2): 508 - 512. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Kai, H. Okabayashi, M. Hanyu, Y. Soga, T. Nomoto, J. Nakano, T. Matsuo, E. Umehara, and M. Kawato Long-Term Results of Bilateral Internal Thoracic Artery Grafting in Dialysis Patients Ann. Thorac. Surg., May 1, 2007; 83(5): 1666 - 1671. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Esaki, T. Koshiji, M. Okamoto, M. Tsukashita, T. Ikuno, and R. Sakata Gastroepiploic Artery Grafting Does Not Improve the Late Outcome in Patients With Bilateral Internal Thoracic Artery Grafting Ann. Thorac. Surg., March 1, 2007; 83(3): 1024 - 1029. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Soga, S. Takai, H. Okabayashi, A. Nagasawa, T. Yokota, K. Nishimura, M. Miyazaki, and M. Komeda Human gastroepiploic artery has greater chymase activity than the internal thoracic artery Eur. J. Cardiothorac. Surg., December 1, 2006; 30(6): 877 - 880. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J.F. Baskett, F. H. Cafferty, S. J. Powell, R. Kinsman, B. E. Keogh, and S. A.M. Nashef Total Arterial Revascularization is Safe: Multicenter Ten-Year Analysis of 71,470 Coronary Procedures Ann. Thorac. Surg., April 1, 2006; 81(4): 1243 - 1248. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Nishida, Y. Tomizawa, M. Endo, and H. Kurosawa Survival Benefit of Exclusive Use of In Situ Arterial Conduits Over Combined Use of Arterial and Vein Grafts for Multiple Coronary Artery Bypass Grafting Circulation, August 30, 2005; 112(9_suppl): I-299 - I-303. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Formica, O. Ferro, P. Greco, A. Martino, D. Gastaldi, and G. Paolini Long-term follow-up of total arterial myocardial revascularization using exclusively pedicle bilateral internal thoracic artery and right gastroepiploic artery Eur. J. Cardiothorac. Surg., December 1, 2004; 26(6): 1141 - 1148. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Verma, P. E. Szmitko, R. D. Weisel, D. Bonneau, D. Latter, L. Errett, Y. LeClerc, and S. E. Fremes Should Radial Arteries Be Used Routinely for Coronary Artery Bypass Grafting? Circulation, August 3, 2004; 110(5): e40 - e46. [Full Text] [PDF]
|
|
|
|
|
|
G. Tavilla, A. P. Kappetein, J. Braun, J. Gopie, A. T. J. Tjien, and R. A. E. Dion Long-term follow-up of coronary artery bypass grafting in three-vessel disease using exclusively pedicled bilateral internal thoracic and right gastroepiploic arteries Ann. Thorac. Surg., March 1, 2004; 77(3): 794 - 799. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Unger, P. W. Serruys, M. H. Yacoub, C. Ilsley, P. K. Paulsen, T. T. Nielsen, L. Eysmann, and F. Kiemeneij Revascularization in multivessel disease: Comparison between two-year outcomes of coronary bypass surgery and stenting J. Thorac. Cardiovasc. Surg., April 1, 2003; 125(4): 809 - 820. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Endo, H. Nishida, Y. Tomizawa, and H. Kasanuki Benefit of Bilateral Over Single Internal Mammary Artery Grafts for Multiple Coronary Artery Bypass Grafting Circulation, October 30, 2001; 104(18): 2164 - 2170. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Nishida, Y. Tomizawa, M. Endo, H. Koyanagi, and H. Kasanuki Coronary Artery Bypass With Only In Situ Bilateral Internal Thoracic Arteries and Right Gastroepiploic Artery Circulation, September 18, 2001; 104 (2009): I-76 - I-80. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O. Wendler, P. Landwehr, D. Bandner-Risch, T. Georg, and H.-J. Schafers Vasoreactivity of arterial grafts in the patient with diabetes mellitus: investigations on internal thoracic artery and radial artery conduits Eur. J. Cardiothorac. Surg., August 1, 2001; 20(2): 305 - 311. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Abizaid, M. A. Costa, M. Centemero, A. S. Abizaid, V. M.G. Legrand, R. V. Limet, G. Schuler, F. W. Mohr, W. Lindeboom, A. G.M.R. Sousa, et al. Clinical and Economic Impact of Diabetes Mellitus on Percutaneous and Surgical Treatment of Multivessel Coronary Disease Patients: Insights From the Arterial Revascularization Therapy Study (ARTS) Trial Circulation, July 31, 2001; 104(5): 533 - 538. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. W. Serruys, F. Unger, J. E. Sousa, A. Jatene, H. J.R.M. Bonnier, J. P.A.M. Schonberger, N. Buller, R. Bonser, M. J.B. van den Brand, L. A. van Herwerden, et al. Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease N. Engl. J. Med., April 12, 2001; 344(15): 1117 - 1124. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Matsuura, K. Yasuura, K. Yoshida, H. Oshima, S. Tomari, H. Ishida, S. Mori, G. Fujii, and K. Iwata Transplantation of the en bloc vascular system for coronary revascularization J. Thorac. Cardiovasc. Surg., March 1, 2001; 121(3): 520 - 525. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Ura, R. Sakata, Y. Nakayama, Y. Arai, and T. Saito Long-term results of bilateral internal thoracic artery grafting Ann. Thorac. Surg., December 1, 2000; 70(6): 1991 - 1996. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Yasuura, Y. Takagi, Y. Ohara, Y. Takami, A. Matsuura, and H. Okamoto Theoretical analysis of right gastroepiploic artery grafting to right coronary artery Ann. Thorac. Surg., March 1, 2000; 69(3): 728 - 731. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O. Wendler, B. Hennen, T. Markwirth, J. Konig, D. Tscholl, Q. Huang, E. Shahangi, H.-J. Schafers, and S. H. G. Borst T GRAFTS WITH THE RIGHT INTERNAL THORACIC ARTERY TO LEFT INTERNAL THORACIC ARTERY VERSUS THE LEFT INTERNAL THORACIC ARTERY AND RADIAL ARTERY: FLOW DYNAMICS IN THE INTERNAL THORACIC ARTERY MAIN STEM J. Thorac. Cardiovasc. Surg., November 1, 1999; 118(5): 841 - 848. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O. Jegaden, L. Bontemps, G. de Gevigney, C. Chatel, R. Itti, and P. Mikaeloff Two-year assessment by exercise Thallium scintigraphy of myocardial revascularization using bilateral internal mammary and gastroepiploic arteries Eur. J. Cardiothorac. Surg., August 1, 1999; 16(2): 131 - 134. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Borst and P. F. Grundeman Minimally Invasive Coronary Artery Bypass Grafting : An Experimental Perspective Circulation, March 23, 1999; 99(11): 1400 - 1403. [Full Text] [PDF]
|
|
|
|
|
|
F. D. Loop Coronary artery surgery: the end of the beginning Eur. J. Cardiothorac. Surg., December 1, 1998; 14(6): 554 - 571. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 All Arterial Grafts Yield a Better Outcome Journal Watch Cardiology, July 24, 1998; 1998(724): 10 - 10. [Full Text]
|
|
|
|
|
|
D. A. Cooley Coronary Bypass Grafting With Bilateral Internal Thoracic Arteries and the Right Gastroepiploic Artery Circulation, June 23, 1998; 97(24): 2384 - 2385. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||