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Ann Thorac Surg 1995;59:1228-1230
© 1995 The Society of Thoracic Surgeons

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Case Report

Severe Internal Mammary Artery Atherosclerosis After Correction of Coarctation of the Aorta

Department of Cardiovascular Surgery, Texas Heart Institute/St. Luke's Episcopal Hospital, Houston, Texas

Accepted for publication October 6, 1994.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
Recently, we were unable to use the left internal mammary artery for coronary artery bypass grafting in 2 patients who had undergone successful late correction of coarctation of the aorta. In both patients, the mammary arteries were severely atherosclerotic and calcified; this may have resulted from prolonged and severe obstructive hypertension, which both patients had sustained before repair of the coarctation. Thus, in patients who have undergone late repair of coarctation, a bypass conduit other than the mammary artery may be needed.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment References

 
Coronary artery disease is the most common cause of late death after repair of coarctation of the aorta [1, 2]. Recently, we were unable to use the left (LIMA) or right internal mammary artery for coronary artery bypass grafting (CABG) in 2 patients who had undergone successful late correction of coarctation. In both patients, the mammary arteries were severely atherosclerotic and calcified and were unsuitable for bypass grafting, a condition that is rarely seen in the general population [3–5].

	Case Reports

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Patient 1
In June 1991, we performed CABG in a 71-year-old man who had angina pectoris and severe multivessel coronary disease. The patient had undergone correction of coarctation of the aorta by resection and end-to-end anastomosis at the age of 35 years and bilateral carotid endarterectomy at the age of 67 years. He had a small, nondominant right coronary artery with a 70% stenosis at its midportion. There was no left main coronary artery, and the left anterior descending coronary artery (LAD) and circumflex artery had separate ostia. The LAD had a 70% stenosis at the ostium, a 90% stenosis above the diagonal branch, and a 70% stenosis below the diagonal branch. The circumflex artery had a moderate stenosis at the ostium and a 70% stenosis at the proximal third portion.

Although we had intended to use the LIMA as a bypass graft to the LAD, on examination, we found the LIMA to be unusually large and heavily calcified with a very weak pulse. Transection revealed that the lumen was less than 0.5 mm in diameter. Therefore, we used saphenous vein grafts to bypass the LAD, the diagonal branch, and the posterior descending branch of the circumflex coronary artery. The patient did well after the operation and was discharged on postoperative day 8. At the 3-year follow-up, he is alive and well.

Pathologic examination of the LIMA revealed severely calcified plaque along its entire length (Fig 1). After decalcification, several sections of the artery were examined by microscopy. Extracellular lipid deposits were found within the intima; the deposits were surrounded by a hyalinized zone containing myofibroblasts and mononuclear cells.

View larger version (2K): [in this window] [in a new window]   Fig 1. . (Patient 1.) Extensive calcification of the left internal mammary artery, opened longitudinally.

At operation, the LIMA was found to be even more heavily calcified than the LIMA in patient 1, and it was virtually pulseless. The right internal mammary artery also was explored; the extent of plaque was similar to that in the left. Because both internal mammary arteries were unsuitable, we used saphenous vein grafts to bypass the LAD and obtuse marginal arteries. The patient was discharged on postoperative day 4 and was doing well at the 7-month follow-up.

	Comment

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Because of their excellent long-term patency rates and freedom from ischemic events, the internal mammary arteries have become the preferred conduits for CABG [6]. We believe use of the mammary arteries for CABG can be extended to include those patients who have undergone repair of coarctation of the aorta. In our 2 patients, however, the internal mammary arteries had become severely calcified and were unsuitable for CABG, which necessitated our using the saphenous vein as the bypass conduit. In both patients, repair of coarctation had been undertaken late (at ages 35 and 23 years). In addition, both patients had severe obstructive hypertension at the time of coarctation repair. Possibly, the prolonged period of hypertension may have contributed to the severe calcification and atherosclerosis found in both patients' internal mammary arteries. An interesting, but unrelated finding in each patient was absence of the left main coronary artery, another condition rarely seen in the general population [7].

As many as two thirds of patients who survive coarctation repair ultimately die of coronary artery disease [1, 2] and may require CABG. In such patients who have undergone late repair, surgeons should be aware of the possibility that the mammary arteries may be unsuitable for use as bypass conduits.

	Footnotes

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Address reprint requests to Dr Cooley, Texas Heart Institute, PO Box 20345, Houston, TX 77225-0345.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. Cohen M, Fuster V, Steele PM, Driscoll D, McGoon DC. Coarctation of the aorta: long-term follow-up and prediction of outcome after surgical correction. Circulation 1989;80:840–5.[Abstract/Free Full Text]
2. Lawrie GM, DeBakey ME, Morris GC, Crawford ES, Wagner WF, Glaeser DH. Late repair of coarctation of the descending thoracic aorta in 190 patients. Arch Surg 1981;116:1557–60.[Abstract/Free Full Text]
3. Van Son JA, Smedts F, Vincent JG, VanLier HJ, Kubat K. Comparative anatomic studies of various arterial conduits for myocardial revascularization. J Thorac Cardiovasc Surg 1990;99:703–7.[Abstract]
4. Julke M, von Segesser L, Schneider J, Turina M, Heitz PU. Degree of atherosclerosis of the internal mammary artery and of the coronary arteries in 45- to 75-year-old men. An autopsy study. Schweiz Med Wochenschr 1989;199:1219–23.
5. Heggtveit HA, Lobo FV. Atherosclerosis in internal mammary arteries selected for coronary artery bypass grafting. Can J Cardiol 1992;8:50–2.[Medline]
6. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1–6.[Abstract]
7. Topaz O, DiSciascio G, Cowley MJ, et al. Absent left main coronary artery: angiographic findings in 83 patients with separate ostia of the left anterior descending and circumflex arteries at the left aortic sinus. Am Heart J 1991;122:447–52.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): George J. Reul Denton A. Cooley Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chen, R. H.-T. Articles by Cooley, D. A. Search for Related Content PubMed PubMed Citation Articles by Chen, R. H.-T. Articles by Cooley, D. A.