Ann Thorac Surg 1999;67:1783-1785
© 1999 The Society of Thoracic Surgeons
Case Reports
Coronary revascularization with arterial conduits collateral to the lower limb
Tsuyoshi Shimizu, MDa,
Tetsuzo Hirayama, MDa,
Katsusuke Ikeda, MDa,
Shigeki Ito, MDa,
Shin Ishimaru, MDa
a Department of Surgery II, Tokyo Medical University, Tokyo, Japan
Accepted for publication November 7, 1998.
Address reprint requests to Dr Shimizu, Department of Surgery II, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, Japan
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Abstract
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A 62-year-old man with left main coronary artery disease had coronary artery bypass grafting. Angiography disclosed total occlusion of the left common iliac artery. The left internal thoracic artery and the left inferior epigastric artery were well developed as collateral pathways to the left external iliac artery. With concomitant femoro-femoral crossover bypass, these two large arterial conduits were harvested and grafted to the coronary artery.
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Introduction
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The use of the internal thoracic artery (ITA) in coronary revascularization as a pedicle graft is broadly accepted because of its high patency rate compared with that of the saphenous vein [1]. The inferior epigastric artery (IEA) also has been used as an arterial bypass conduit; however, harvesting of IEA grafts is limited in order to obtain an adequate caliber similar to that of ITA grafts [2]. We encountered a patient in whom the ITA and the IEA were well developed as collateral pathways to the lower limb and performed coronary artery bypass with those arterial conduits, after providing alternative blood supply to the lower limb.
A 62-year-old man with unstable angina was referred to our institute for a coronary artery bypass operation. He had a history of diabetes, hypertension, and intermittent claudication. Coronary angiography found 75% stenosis of the left main coronary artery and 90% stenosis of the origin and the middle section of the left circumflex coronary artery. The right coronary artery was diffusely stenotic and small, and the posterior descending artery arose from the left circumflex coronary artery. Left ventriculography showed no abnormality, with an ejection fraction of 60%. The left iliac artery was occluded at its origin. Selective angiography showed the left ITA collateral to the left external iliac artery via the left IEA (Fig 1). The left femoral arterial pulse was barely palpable. The ankle-brachial pressure index was 0.67 in the left lower limb and 1.12 in the right lower limb.
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Fig 1. Selective angiography of the left internal thoracic artery showed it (closed arrows) to be collateral to the left external iliac artery (open arrow) via the left superior epigastric artery (open arrowheads) and the left inferior epigastric artery (closed arrowheads). The distal segment of the left external iliac artery and the left femoral artery were filled by collateral flow from this pathway. The caliber of the left internal thoracic artery and the left inferior epigastric artery was considerably larger than usual.
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The patient had coronary artery bypass grafting. Femoro-femoral crossover bypass grafting was done using a woven 6-mm diameter Dacron graft. The left ITA, the left IEA, and the right gastroepiploic artery were dissected simultaneously with the peripheral vascular reconstruction. The free IEA graft was placed to the obtuse marginal branch. The in situ left ITA graft was grafted to the left anterior descending artery. The in situ right gastroepiploic artery graft was anastomosed to the posterior descending artery. The proximal IEA graft anastomosis was made to the ITA graft as a Y graft. The distal ITA and IEA grafts were 3 mm in diameter. Cardiopulmonary bypass discontinued without difficulty. The patient was asymptomatic 6 months postoperatively.
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Comment
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Patients with peripheral vascular disease have a high prevalence of coronary artery disease and frequently undergo coronary artery bypass grafting. The presence of peripheral vascular disease increases in-hospital mortality rates in patients who have coronary artery bypass operations [3]. Conversely, coronary revascularization has beneficial effects on long-term outcome in patients with peripheral vascular disease [4].
In this patient, peripheral vascular disease was detected by coronary angiography. If the left ITA had been harvested without angiography, a catastrophic complication of an ischemic lower limb might have developed. When the common iliac artery is obstructed, the main collateral routes are generally the inferior mesenteric artery and the lumbar arteries [5]. The ITA as a collateral pathway to the lower limb in response to aortic or iliac artery occlusion rarely has been demonstrated angiographically [6]. Routine preoperative angiography of the ITA is usually considered unnecessary; however, the status of the ITA should be verified in patients with aorto-iliac occlusive disease who have coronary artery bypass operations.
When one ITA is collateral to the lower limb, the other ITA could be used alternatively in patients with coronary artery disease and peripheral vascular disease. Parashara and associates [6] reported a patient in whom the left ITA supplied the left external iliac artery. They preserved the left ITA to prevent postoperative limb ischemia and anastomosed the right ITA and two saphenous vein grafts. In our patient, peripheral vascular procedures were performed concomitantly with coronary revascularization. We believe peripheral vascular bypass grafting for intermittent claudication produces optimal short-term and long-term results [7]. Because adequate blood flow to the lower limb was established, two large grafts were obtained without difficulty. Although the proximal anastomosis of the IEA graft could have been made on the ascending aorta, it was placed on the ITA graft to prevent direct exposure to left ventricular pressure [2]. Hypoperfusion syndrome is a potential pitfall after myocardial revascularization using composite arterial conduits. In this patient, as the size of the ITA and the IEA was considerably larger than usual, a composite Y graft was considered to be a better conduit to achieve revascularization with only arterial conduits. By using multiple sequential bypass techniques [8], such grafts could reach any coronary arteries and achieve complete revascularization without other graft conduits.
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Acknowledgments
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The authors are indebted to Prof Brian Buxton, Austin & Repatriation Medical Centre, Melbourne, Australia for review of this manuscript.
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References
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Birkmeyer J.D., Quinton H.B., O’Connor N.J., et al. The effect of peripheral vascular disease on long-term mortality after coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group. Arch Surg 1996;131:316-321.[Abstract/Free Full Text]
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Abstract
Introduction
