Ann Thorac Surg 1999;67:1800-1801
© 1999 The Society of Thoracic Surgeons
Case Reports
Late vasospasm of the inferior epigastric artery graft
Yukio Ichikawa, MDa,
Hirokazu Kajiwara, MDa,
Toshiyuki Hamada, MDa,
Ichiya Yamazaki, MDa,
Yasuyuki Jin, MDa,
Sunao Sato, MDa
a Department of Cardiovascular Surgery, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
Accepted for publication November 17, 1998.
Address reprint requests to Dr Ichikawa, Department of Cardiovascular Surgery, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka Higashi, Kanazawa-ku, Yokohama 236, Japan
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Abstract
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We report a case of vasospasm of a free inferior epigastric artery graft at 5-year angiographic follow-up after coronary artery bypass grafting. Although the cause of spasm was not clear, the graft was viable and had a vasoconstrictor profile similar to a gastroepiploic artery graft at long-term follow-up.
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Introduction
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Many experiences with the inferior epigastric artery (IEA) as an alternative conduit for coronary artery bypass grafting (CABG) have been reported. However, long-term reliability of the IEA graft after CABG has not been determined. To help in this evaluation, we report a case of vasospasm of a free IEA graft several years after CABG.
A 53-year-old man had a history of progressive angina on exertion. Coronary angiography showed a 60% stenosis of the left main trunk and the left anterior descending coronary artery, a 90% stenosis of the right posterior descending coronary branch, and mild stenosis of the circumflex artery. The patient underwent triple CABG: a left internal thoracic artery (ITA) graft to the obtuse marginal branch, a right ITA graft to the left anterior descending coronary artery, and a free IEA graft to the right posterior descending branch. The recovery was uneventful.
Six months postoperatively, coronary angiography showed all the arterial grafts to be widely patent (Fig 1). However, from 3 years after CABG, the patient sometimes experienced angina on exertion. A treadmill test demonstrated ischemic changes in the inferior wall of the heart. Because the patient was asymptomatic at rest, medical therapy with topical nitroglycerin was advised. Repeat coronary angiography was carried out 5 years after CABG according to the arterial revascularization protocol. Before angiography, nitroglycerin (0.3 mg) was sprayed under the tongue to prevent coronary spasm. The right ITA was widely patent, but the left ITA was occluded, and there was a 99% stenosis of the IEA graft (Fig 2). Repeat IEA angiography for percutaneous transluminal coronary angioplasty 2 weeks later showed that the IEA graft was again patent (Fig 3). The patient was on a regimen of the antiplatelet drug trapidil (300 mg/day) but had no calcium antagonist medication at the time of the spasm. After this event, the antiplatelet drug aspirin (81 mg/day) was added and the patient has been asymptomatic without reoperation.
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Fig 2. Five years after coronary artery bypass grafting, there was a distinct spasm of the inferior epigastric artery graft.
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Comment
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Many arterial conduits including the ITA, the right gastroepiploic artery (GEA), the IEA, and the radial artery have been used for myocardial revascularization. Histologic studies of these conduits have demonstrated that the media of the ITA has a preponderantly elastic pattern (with the proximal and distal segments most commonly having an elastomuscular pattern). In contrast, the media of the other arterial conduits, including the IEA, is purely muscular [1]. The media of the ITA consists of elastic lamellae with dispersed smooth muscle cells and collagen, with internal and external elastic laminae. The IEA media, on the other hand, comprises many smooth muscle cells and is limited by the internal and external elastic laminae as in the right GEA and radial artery [1].
The ITA is thought to be nourished by diffusion of substrates from the intraluminal blood as are the avascular zones of larger arteries. The maximum number of lamellae in the subintimal avascular zone is much higher in the ITA than in the IEA. These factors suggest that the IEA can be harvested as a free graft without the risk of medial ischemic necrosis [2].
The right GEA graft is thought to be more prone to vasospasm than the ITA graft [3]. Cases of vasospasm of free and in situ GEA grafts have been reported [3, 4]. The IEA has similar structural characteristics as the GEA [1, ]. In addition, the IEA is considered to have a specific receptor-mediated vasoconstrictor profile pharmacologically, which may influence its performance as a bypass graft [5].
Catheter stimulation was considered a cause of spasm in our patient, but an angiogram catheter was not placed distally in the vessel prior to the angiography showing the spasm. Nitroglycerin injection through a catheter was not done at the time of the spasm because we were under the impression that the stenosis of the IEA was due to organic disease. Therefore we do not know whether a spasm responds to nitroglycerin injection. However, nitroglycerin spray under the tongue before angiography did not prevent spasm of the IEA.
Although a cause of spasm was not clear in our patient, we concluded that the free IEA graft was viable and had a similar vasoconstrictor profile as the GEA at long-term follow-up. As the patient’s condition improved with the addition of antiplatelet medication, platelets might have mediated the spasm.
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References
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Van Son J.A., Smedts F., Vincent J.G., van Lier H.J., Kubat K. Comparative anatomic studies of various arterial conduits for myocardial revascularization. J Thorac Cardiovasc Surg 1990;99:703-707.[Abstract]
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Buche M., Schoevaerdts J.C., Louagie Y., et al. Use of the inferior epigastric artery for coronary bypass. J Thorac Cardiovasc Surg 1992;103:665-670.[Abstract]
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Mills N.L., Everson C.T. Right gastroepiploic artery: a third arterial conduit for coronary artery bypass. Ann Thorac Surg 1989;47:706-711.[Abstract]
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Suma H. Spasm of the gastroepiploic artery graft. Ann Thorac Surg 1990;49:168-169.[Medline]
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Tadjkarimi S., O’Neil G.S., Schyns C.J., Borland J.A.A., Chester A.H., Yacoub M.H. Vasoconstrictor profile of the inferior epigastric artery. Ann Thorac Surg 1993;56:1090-1095.[Abstract]
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Abstract
Introduction
