Asian Cardiovasc Thorac Ann 2002;10:254-255
© 2002 Asia Publishing EXchange Pte Ltd
Limb Ischemia Due to Use of Internal Thoracic Artery in Coronary Bypass
Fikri Yapici, MD,
Aybanu G Tuygun, MD,
Ibrahim A Tarhan, MD,
Mehmet Yilmaz, MD,
Abdullah K Tuygun, MD,
Nihan Yapici, MD1,
Azmi Özler, MD
Department of Cardiovascular Surgery
1 Department of Anesthesiology Siyami Ersek Thoracic and Cardiovascular Surgery Center Istanbul, Turkey
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For reprint information contact: Fikri Yapici, MD Tel: 90 216 348 2454 Fax: 90 216 449 3686 email: fyapici{at}turk.net Bagdat Cad 163/4, Selamicesme, Kadikoy, Istanbul 81030, Turkey.
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ABSTRACT
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Immediately after undergoing coronary bypass grafting using the left internal thoracic artery, a 59-year-old man developed left leg ischemia. Right-to-left femoral artery crossover bypass was performed and the ischemia resolved. A 72-year-old man developed left calf pain 12 days after a similar procedure; peripheral angiography revealed stenosis of the abdominal aorta and distal peripheral arteries, which did not require intervention.
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INTRODUCTION
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Recently, internal thoracic artery (ITA) has emerged as the preferred conduit for coronary artery bypass grafting (CABG). In our clinic, ITA is the first choice in most cases (98%). However, the ITA may be essential for collateral supply in the patient with obstruction of the aortoiliac arterial system, and use of the ITA for CABG may cause significant ischemia in the lower extremity. We encountered 2 patients with limb-threatening ischemia (incidence, 2/1,700; 0.12%) in whom an ITA had been used for CABG.
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CASE REPORTS
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CASE 1
A 59-year-old man was operated upon urgently because of unstable angina pectoris. His angiogram demonstrated 90% proximal stenosis of the left anterior descending coronary artery (LAD). His left ITA was used as a conduit for CABG. In the 5th postoperative hour, he complained of numbness of the left leg, and his pulses were not palpable. Thereupon, a right femoral artery-to-left femoral artery crossover bypass was performed with an 8-mm spiral polytetrafluoroethylene graft. The ischemic problems resolved and the patient was discharged from the hospital with no further complications.
CASE 2
A 72-year-old man had 90% proximal stenosis of the LAD, 85% proximal stenosis of the intermediate artery, 90% stenosis of the main stem of the right coronary artery, and 80% stenosis of the posterior descending branch of the right coronary artery. Elective CABG was performed. The left ITA was anastomosed to the LAD, and the other coronary vessels were bypassed using saphenous vein, in the standard fashion. The postoperative course was uneventful until the 12th day when left calf pain occurred even at rest, which was suspected to be due to an occlusive arterial lesion in the leg. Peripheral angiography revealed 70% stenosis of the abdominal aorta at the level of the bifurcation, and noncritical stenosis of the distal peripheral arteries. These lesions necessitated no intervention.
Selective left ITA angiography had not been performed in either of these patients. However, during conduit preparation, it was observed that the free flow of the artery was higher than normal. The ITA was tortuous and had a diameter greater than 4 mm in both patients. It was not apparent that the ITA supplied the iliofemoral arterial system via collaterals; therefore, it was used for coronary bypass.
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DISCUSSION
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The presence of peripheral vascular disease increases hospital mortality and morbidity after coronary bypass operations.1 It is thought that the cause of acute limb-threatening ischemia after cardiac operations may be multifactorial, resulting from events such as insufficient perfusion during cardiopulmonary bypass, low cardiac output in the early postoperative period, overuse of vasopressors, atheromatous embolization, postoperative thrombosis of the native vessels, and interruption of ITA collateral pathways. Interruption of critical collaterals from the ITA is considered to be the major cause of acute limb-threatening ischemia.2
Some patients with occlusion at the aortoiliac level have ITA collaterals to the superior and inferior epigastric artery as a source of supply to the iliac artery; this has been described as the "Winslow pathway".3 Serious limb-threatening ischemia may result from loss of collateral pathways due to interruption of the ITA. This rarely seen complication was first described in 1990 by Dietzek and colleagues.4 If peripheral vascular disease is detected, it may be possible to determine the presence of collaterals during coronary angiography. Nevertheless, demonstration of ITA collaterals is very rare in aortoiliac occlusive disease. Routine selective angiography of the ITA is not considered necessary.5 Collateral flow from the ITA or lateral thoracic artery was reported in 12 of 60 patients with unilateral or bilateral common and/or external iliac artery occlusion who were investigated preoperatively by intravenous digital subtraction angiography.6 Before deciding to use ITA in a patient with Leriche’s syndrome, it has been suggested that evaluation of epigastric arterial flow by Doppler ultrasonography, and abdominal aorta and lower extremity flow by angiography would be appropriate.7
When ITA diameter and flow, which depend on factors of sex and age, are greater than expected, the possibility of collaterals should be kept in mind during the operation. In this situation, monitoring of the distal pulses with a pulse oximeter, or digital examination before ITA removal may be useful. In cases of serious peripheral arterial disease, if it is found that the ITA supplies the lower extremity blood flow, an alternative arterial or venous graft should be chosen in order to prevent limb ischemia. On the other hand, CABG with ITA as a conduit and concomitant lower extremity revascularization procedures such as aortobifemoral bypass, extraanatomical bypass, ascending aortoiliac or bifemoral bypass may be acceptable.2,7 In cases where collateral circulation from the ITA is not recognized preoperatively, strict follow-up of the lower extremity is required postoperatively. If elastic bandaging is used on the extremity, checking the peripheral oxygen saturation is of great importance in preventing ischemic complications and ensuring early intervention if necessary. Nevertheless, in such a situation, the patient’s hemodynamic state may contraindicate extensive reoperation, so extraanatomical bypass which is faster and less traumatic is preferred.2
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REFERENCES
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- Dietzek AM, Goldsmith J, Veith FJ, Sanchez LA, Gupta SK, Wengerter KR. Interruption of critical aortoiliac collateral circulation during nonvascular operation: cause of acute limb-threatening ischemia. J Vasc Surg
1990;12:645–53.[Medline]
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- Conrad C, Fries J. Intravenous digital subtraction angiography. Collateral circulation to "empty leg."Acta Radiol Diagn (Stockh)
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- Arnold JR, Greenberg J, Reddy K, Clements S. Internal mammary artery perfusing Leriche’s syndrome in association with significant coronary arteriosclerosis: four case reports and review of literature. Catheter Cardiovasc Interv
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190 - 190.
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ABSTRACT
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