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Limb Ischemia Due to Use of Internal Thoracic Artery in Coronary Bypass

¹ Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland OH, USA
² Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Chiba, Japan

I refer to the article reported by Yapici et al in the Asian Cardiovascular and Thoracic Annals, entitled "Limb Ischemia Due to Use of Internal Thoracic Artery in Coronary Bypass."¹ They presented two patients with left lower leg ischemia that developed after left internal thoracic artery (ITA) grafting. They recommended the assessment of epigastric arterial flow by doppler ultrasound and the examination of the abdominal aorta and iliac artery by angiography if aortoiliac occlusion is suspected. They also suggested the use of pulse oximetery or digital examination of the foot before ITA harvest.

We conducted a study of coronary artery bypass grafting (CABG) in patients with aortoiliac occlusive disease.² We found that the over all prevalence of aortoiliac occlusive disease was 0.7% (13/1794) among the patients undergoing CABG. Aortoiliac occlusive disease was found 11.8% (13/110) among the patients undergoing CABG with a known history of peripheral vascular disease. In patients with aortoiliac occlusive disease, collateral blood flow to the leg can be provided by the ITA, inferior mesenteric artery or lumbar arteries. We developed a strategy for the treatment of patients with both aortoiliac occlusive disease and severe coronary disease who require surgical revascularization. This strategy initially involves the assessment of the collateral supply to the legs. If the patient has a decreased femoral pulse, and aortoiliac occlusive disease is suspected, ITA angiography should be performed. The ITA may provide the main collateral supply to the ipsilateral leg via the inferior epigastric artery (IEA). Confirmation of this route, via ITA-IEA to the leg, requires catheterization exclusively from the upper extremities. Selective angiography of the ITA requires a relatively long period of exposure time and also requires the adjustment of the capturing flame of the picture from the subclavian artery to the femoral artery. If the lumbar artery or inferior mesenteric artery supply the collateral flow, and not the ITA-IEA, then CABG using the ITAs is considered to be safe. However, if the ITA supplies the only source of blood flow to the leg, the ITA should not be harvested, and alternative conduits should be selected for CABG. If the patient develops chest symptoms, CABG should be performed first, but surgeons should consider that an intra-aortic balloon pump cannot be used in patients with aortoiliac occlusive disease, even if the patient develops post-surgical low output syndrome. If the patient has stable angina, revascularization of the aortoiliac vessels should be performed prior to CABG. After revascularization of the leg, the ITA can be used without compromising blood flow to the leg, and the insertion of an intra-aortic balloon pump can be performed safely, if indicated.

I consider that pulse oximetery of the foot is not practical method of identifying the ITA-IEA collaterals, as the feet are in the operative field of most cardiac operations. However, I strongly recommend the examination of the femoral pulse prior to surgery. If the femoral pulse is unable to be palpated, and if the presence of a collateral supply to the leg, other than the ITA-IEA collaterals has not been identified, the patient should not undergo ITA harvest, because postoperative leg ischemia would be inevitable.

REFERENCES

1. Yapici F, Tuygun AG, Tarhan I, Yilmaz M, Tuygun AK, Yapici N, et al. Limb ischemia due to use of internal thoracic artery in coronary bypass. Asian Cardiovasc Thorac Ann 2002;10:254–5.[Abstract/Free Full Text]

2. Hirose H, Amano A, Takahashi A, Takanashi S. Coronary artery bypass grafting for patients with aortoiliac occlusive disease. Vascular and Endovascular Surgery 2002;36:285–90.

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