Asian Cardiovasc Thorac Ann 2004;12:366-368
© 2004 Asia Publishing EXchange Ltd
Coronary Artery Bypass Grafting with Left Inferior Epigastric Artery as Collateral
Osami Honjo, MD,
Osamu Oba, MD,
Takeshi Shichijo, MD,
Keiji Yunoki, MD,
Masahiro Inoue, MD,
Takanori Suezawa, MD
Department of Cardiovascular Surgery Hiroshima City Hospital Hiroshima, Japan
For reprint information contact: Osami Honjo, MD Tel: 81 86 235 7359 Fax: 81 86 235 7431 Email: osami47{at}hotmail.com Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata, Okayama City, Okayama 700–8558, Japan.
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ABSTRACT
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We report a case of co-existent coronary and peripheral vascular disease with collaterals to the lower extremities in a 72-year-old female. The patient had triple-vessel coronary artery disease, an occlusion of the bilateral iliac arteries, and the left internal mammary-inferior epigastric artery collateral pathway was a major route to the lower extremities. Coronary artery bypass grafting and right axillo-bifemoral bypass were performed. The well-developed left inferior epigastric artery was used as a conduit to the circumflex artery.
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INTRODUCTION
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In a situation of an aortic or an iliac occlusion, collateral pathways develop as a blood supply route to the lower extremities.1 The internal mammary artery (IMA)-inferior epigastric artery (IEA) pathway is known to be one of the major collateral routes.2 In our case report of a patient with both coronary and peripheral vascular disease, the left internal mammary artery (LIMA)-IEA collateral pathway was the major route of blood supply to the lower extremities. We used the well-developed IEA as a free graft for a distal target vessel in coronary artery bypass grafting (CABG).
A 72-year-old female with angina pectoris was referred to our institution for surgery. She had a long history of smoking and diabetes mellitus, and had experienced intermittent claudication. Peripheral arteries of the lower extremities were not pulsated. The ankle-brachial pressure indices were 0.46 on the right side and 0.45 on the left. Coronary angiography revealed 90% stenosis in the proximal left anterior descending artery, 90% stenosis in the distal circumflex artery and 75% stenosis in the distal right coronary artery. An abdominal aortography revealed an occlusion of the bilateral common iliac arteries at their origin with collateral vessels such as the inferior mesenteric artery and some lumbar arteries (Figure 1
). Selective angiography of the LIMA showed that the leg vessels had been opacified via the LIMA-IEA collateral pathway (Figure 2). Off-pump CABG and right axillo-bifemoral bypass were scheduled.
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Figure 1. An abdominal aortogram showing total occlusion of the bilateral common iliac arteries with collaterals to the lower extremities.
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Figure 2. Selective angiography of the LIMA-IEA collateral pathway to the lower extremities. The arrow points to the well-developed left inferior epigastic artery.
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During surgery, the LIMA and IEA were harvested simultaneously. The harvested IEA was 21 cm in length and approximately 4 mm in diameter at the first segment. A free IEA graft was anastomosed to the distal circumflex artery, and the LIMA was anastomosed to the left anterior descending artery. The aorta was partially clamped, and the proximal end of the IEA graft was anastomosed directly onto the ascending aorta. The distal right coronary artery was hypoplastic and was therefore ungraftable. Thereafter, right axillo-bifemoral bypass was performed using an 8 mm ringed polytetrafluoroethylene graft.
After the operation, the peripheral pulse became palpable and there was no marked elevation of creatine phosphokinase. The postoperative course was uneventful and an angiography showed patency of all coronary artery bypasses. Three years after the operation, the patient remains asymptomatic.
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DISCUSSION
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Although the IMA-IEA collateral pathway is known to be a collateral route of blood supply to the lower extremities,1,2 it has rarely been used in coronary revascularization. Parashara and colleagues reported a patient with both coronary and peripheral vascular disease in which the LIMA-IEA collateral pathway supplied blood flow to the external iliac artery. They preserved the LIMA to prevent ischemia of the lower extremities and used the right IEA and two saphenous vein grafts for CABG without revascularization of the lower extremities.3 Shimizu and co-workers also reported a patient with left main coronary artery disease and peripheral vascular disease in which a well-developed LIMA-IEA collateral supplied blood to the left iliac artery. They used the IEA, which had developed as a collateral artery for CABG and performed femorofemoral crossover bypass concomitantly as in our case.4 As in the two cases above, our patient had total occlusion of the bilateral common iliac arteries and had a LIMA-IEA collateral pathway.
There are some concerns over using the IEA, which has developed as a collateral artery in CABG. First, the long-term quality of the artery is uncertain since it has worked as a collateral for such a long period of time. The IEA in our patient appeared normal with no gross hypertrophy or calcification except for its large caliber. Therefore, the quality of the IEA harvested from our patient was thought to be similar to that of an IEA not used as a collateral vessel. We used this conduit not only because its patency rate is superior to that of a saphenous vein graft,5,6 but also because of the necessity for the preservation of the radial artery due to poorly controlled diabetes as well as renal dysfunction. Second, since the major collateral pathway to the lower extremities is harvested, lower extremity ischemia during CABG preceding lower revascularization should be taken into consideration. In our patient, other collateral pathways such as the inferior mesenteric and lumbar arteries were also developed, enabling maintenance of blood supply during the operation. In cases in which the IMA-IEA collateral pathway is the only route of blood supply to the lower extremities, care must be taken to prevent ischemia.
Early postoperative angiography results were excellent; however long-term clinical and angiographic follow-up is necessary. The approach used in our case is an option for patients with combined coronary and peripheral artery disease who possess large collateral arteries.
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REFERENCES
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- Chait A. The internal mammary artery: an overlooked collateral pathway to the leg. Radiology
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- Parashara DK, Kotler MN, Ledley GS, Yazdanfar S. Internal mammary artery collateral to the external iliac artery: an angiographic consideration prior to coronary bypass surgery. Cathet Cardiovasc Diagn
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- Shimizu T, Hirayama T, Ikeda K, Ito S, Ishimaru S. Coronary revascularization with arterial conduits collateral to the lower limb. Ann Thorac Surg
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- Dion R, Glineur D, Derouck D, Verhelst R, Noirhomme P, El Khoury G, et al. Complementary saphenous grafting: long-term follow-up. J Thorac Cardiovasc Surg
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- Buche M, Schroeder E, Gurne O, Chenu P, Paquay JL, Marchandise B, et al. Coronary artery bypass grafting with the inferior epigastric artery. Midterm clinical and angiographic results. J Thorac Cardiovasc Surg
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