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Ann Thorac Surg 1997;63:843-844
© 1997 The Society of Thoracic Surgeons

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Case Reports

Avulsion of the Left Internal Mammary Artery After Minimally Invasive Coronary Bypass

Divisions of Cardiothoracic Surgery and Cardiology, State University of New York at Buffalo and The Buffalo General Hospital, Buffalo, New York

Accepted for publication September 28, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment Reference

 
Minimally invasive direct coronary artery bypass grafting is a relatively new procedure. An unusual complication occurred in a patient after a period of heavy lifting, namely, avulsion of the left internal mammary artery graft. He presented with a clinical picture of myocardial infarction and shock. Diagnostic work-up and surgical management are described.

	Introduction

Top Footnotes Abstract Introduction Comment Reference

 
See also page 844a.

Minimally invasive direct coronary artery bypass grafting is a relatively new procedure introduced into cardiac surgery [1]. Here we report the occurrence of total avulsion of the left internal mammary artery (LIMA) graft, emphasizing the diagnostic work-up and management. The mechanism of this complication is unknown, and the consequences are life-threatening.

A 58-year-old man presented with severe angina due to an ostial lesion of the left anterior descending coronary artery (LAD). He was offered revascularization via a left anterior small thoracotomy approach. A small incision was made in the fourth intercostal space; the LIMA was identified and dissected proximally to the third and distally below the fifth intercostal spaces. It was an excellent conduit. The pericardium was opened and the LAD was prepared for the anastomosis. It was a large (2.5 mm) calcified vessel. A single 7.0 Prolene (Ethicon, Somerville, NJ) running suture was used for construction of the anastomosis. Two Prolene sutures were used to anchor the LIMA pedicle to prevent torsion of the LIMA. Two separate Doppler scans were done to evaluate the graft: the first at 2 hours after the operation and the second on the day of discharge from the hospital. Both scans documented strong diastolic flow components in the LIMA (Fig 1).

View larger version (74K): [in this window] [in a new window]   Fig 1. . Postoperative Doppler study demonstrating strong diastolic flow in the left internal mammary artery ( LIMA) before discharge.

Upon arrival, the patient was alert and pain free, but the electrocardiogram continued to show changes of anterior wall myocardial infarction. Creatine kinase levels were 28, 32, and 157 U/L. His hemodynamic status was optimized with intraaortic balloon pumping, dobutamine, and low-dose dopamine. Duplex scan of the LIMA showed only systolic flow, indicative of occlusion of the LIMA (Fig 2). Transthoracic echocardiogram revealed a moderate pericardial effusion and reduction in ejection fraction from 0.68 to 0.30. Selective coronary and LIMA angiography were performed. The LIMA was occluded distally (Fig 3). The LAD showed critical ostial stenosis and approximately 50% stenosis at the anastomosis but was still patent. The patient was reexplored via sternotomy, and 400 mL of dark blood was evacuated from the pericardial cavity. A dense, fibrinous pericarditis was encountered. The LIMA was isolated and, although it appeared to have enough length, had avulsed at a point 1 cm proximal to the anastomosis. The LIMA dissection was completed proximally and was anastomosed to the LAD after debridement of the vessel edges. A saphenous vein graft was also placed distally on the LAD.

View larger version (98K): [in this window] [in a new window]   Fig 2. . Readmission Doppler scan showing loss of augmented diastolic flow. ( LIMA = left internal mammary artery.)

View larger version (130K): [in this window] [in a new window]   Fig 3. . Angiogram illustrating occluded left internal mammary artery.

	Comment

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During minimally invasive coronary artery bypass grafting, great care is taken to ensure adequate length and smooth course of the conduit. The LIMA pedicle is routinely sutured to the epicardium to prevent torsion about the anastomosis. The initial presentation of this patient was ischemia and infarction. We assumed that the LIMA had occluded due to technical problems, such as injury to the artery during dissection, obstruction of the distal anastomosis, or kinking of the graft. The mechanism by which avulsion of the LIMA occurred is unknown. We postulate that the initiating event was due to a forceful Valsalva maneuver that accompanies heavy lifting. Violent movement of the diaphragm with disruption of the LIMA at the sharp edge of the pericardium is a possibility. Patients who receive the left anterior small thoracotomy procedure are mobilized early and are encouraged to be active. Their activity, however, should be appropriately limited, and heavy lifting should be avoided.

In summary, after an uneventful minimally invasive coronary artery bypass grafting procedure, a patient presented with acute anterior wall ischemia and myocardial infarction. Although it was known that the LIMA was occluded by Doppler scan and angiography, it was only at time of the operation that avulsion of the LIMA from the LAD was discovered. This potentially lethal complication needs to be included in the differential diagnosis of failed minimally invasive coronary artery bypass grafting procedure.

	Footnotes

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Address reprint requests to Dr Salerno, Division of Cardiothoracic Surgery, SUNY at Buffalo, 100 High St, Buffalo, NY 14203.

	Reference

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1. Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658–65.

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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): Jacob Bergsland Tomas A. Salerno Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by McMahon, J. Articles by Salerno, T. A. Search for Related Content PubMed PubMed Citation Articles by McMahon, J. Articles by Salerno, T. A. Related Collections Related Article