Ann Thorac Surg 2000;69:1244-1246
© 2000 The Society of Thoracic Surgeons
CASE REPORTS
Internal mammary artery perfusing the Leriche’s syndrome
John R. Arnold, MDa,
Joel D. Greenberg, MDa,
Scott Clements, RTa
a Florida Hospital & Florida Heart Institute, Orlando, Florida, USA
Address reprint requests to Dr Arnold, Florida Hospital & Florida Heart Institute, 324 East Par St, Orlando, FL 32804
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Abstract
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Two cases of collateral perfusion of a lower extremity, by way of an internal mammary artery, in the presence of Leriche’s syndrome are described. The importance of recognizing this condition prior to coronary artery bypass grafting is emphasized.
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Introduction
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Two patients with symptomatic ischemic heart disease in the presence of Leriche’s syndrome are described. In both cases, severe triple vessel coronary artery disease was found angiographically. The use of the left internal mammary artery as one of the bypass grafts would have been appropriate. In each case, however, it was discovered preoperatively that the left lower extremity was totally dependent on the left internal mammary artery for its perfusion (Fig 1).
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Fig 1. Occluded left common and external iliac arteries. Total collateral perfusion to the left lower extremity through the left inferior epigastric artery.
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Case reports
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Patient 1
A 69-year-old man presented with bilateral claudication of the lower extremities and ischemic cellulitis of the right foot. Cardiac catheterization demonstrated severe triple vessel occlusive disease and left ventricular inferior akinesis. Abdominal aortogram with peripheral run-offs revealed total infrarenal occlusion of the aorta (Fig 2A). Selective injection of the left internal mammary artery documented a rich anastomosis between the superior and inferior epigastric arteries with retrograde flow to the left external iliac artery providing total perfusion of the left lower extremity (Fig 2B). A quadruple coronary artery bypass graft was performed using vein grafts. Six days later aortobifemoral bypass grafting was done with amputation of the right great toe.
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Fig 2. (A) Total occlusion of infrarenal abdominal aorta. (B) Cine frame illustrating superior epigastric artery anastomosing with inferior epigastric artery overlying a nephrogram.
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Patient 2
A 61-year-old man presented with unstable angina pectoris and claudication involving both lower extremities. Cardiac catheterization demonstrated severe occlusive triple vessel disease. Abdominal aortogram and femoral arteriogram with run-offs revealed occlusion of the left common iliac artery with no visible perfusion to the viable left lower extremity (Fig 3A). Injection of the left internal mammary artery demonstrated an exceptionally large vessel, including its superior epigastric branch. This provided collateral flow to the left inferior epigastric artery to its origin at the left external iliac artery, with uninterrupted perfusion of the left lower extremity (Fig 3B).
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Fig 3. (A) Occluded left common iliac artery with no visible perfusion to the viable left lower extremity. (B) Large left superior epigastric artery with collateralization to the left inferior epigastric artery.
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Comment
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In the presence of Leriche’s syndrome, one could assume that perfusion of a lower extremity by way of its ipsilateral internal mammary artery is a rare entity. Several cases have been reported in recent years based on presumed clinical data without preoperative angiographic documentation [1–5]. In each case, the internal mammary artery used for coronary bypass grafting was described as exceptionally large, and an acutely ischemic limb was encountered postoperatively on the ipsilateral side. The second of the 2 cases in this report was described in a recent publication [6]. With the addition of patient 1, it is likely that this condition may not be rare.
Doctor Alan M. Dietzek has urged that a duplex scan or Doppler evaluation of the inferior epigastric artery be performed before coronary artery bypass grafting in patients with Leriche’s syndrome [7]. These screening techniques should provide evidence if there is reversal of flow in the inferior epigastric arteries [8]. We suggest, in this circumstance, that an abdominal aortogram and femoral arteriogram should be included in the preoperative angiographic investigation. If perfusion to either lower extremity is not fully established, or there is Doppler evidence of reversal of inferior epigastric artery flow, selective injection of the ipsilateral internal mammary artery should be done before the vessel is diverted to the coronary circulation.
Two cases of Leriche’s syndrome, with perfusion of the left lower extremity by collateral flow from the left internal mammary artery, are described with preoperative angiographic documentation. Recent case reports indicate that this entity may not be rare. If an internal mammary artery graft is anticipated with coronary artery operation in the presence of Leriche’s syndrome, Doppler assessment of inferior epigastric flow, or angiography of the abdominal aorta and lower extremities, should be done preoperatively. If perfusion to either limb is not fully established, or reversed inferior epigastric artery flow is suspected, selective injection of the ipsilateral internal mammary artery should be included to avoid the risk of an acutely ischemic limb postoperatively.
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References
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Dietzek A., Goldsmith J., Veith F., Sanchez L., Gupta S., Wengerter K. Interruption of critical aortoiliac collateral circulation during nonvascular operations. J Vasc Surg 1990;12:645-653.[Medline]
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Collier P. Discussion of Dietzek A, Goldsmith J, Veith F, Sanchez L, Gupta S, Wengerter K. Interruption of critical aortoiliac collateral circulation during nonvascular operations. J Vasc Surg 1990;12:652.
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Kitamura S., Inoue K., Kawachi K., et al. Lower extremity ischemia secondary to internal thoracic-coronary artery bypass grafting. Ann Thorac Surg 1993;56:157-159.[Abstract]
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Tsui S.S.L., Parry A.J., Large S.R. Leg ischemia following bilateral internal thoracic artery and inferior epigastric artery harvesting. Eur J Cardiothorac Surg 1995;9:218-220.[Abstract]
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Melissano C., Di Credico G., Chiesa R., Grossi A. The use of internal thoracic arteries for myocardial revascularization may produce acute leg ischemia in patients with concomitant Leriche’s syndrome. J Vasc Surg 1996;24:698.[Medline]
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Arnold JR. Leriche’s syndrome with total perfusion of the left lower extremity by way of the left internal mammary artery. Am J Card 1198;82:997–9.
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Dietzek A. Discussion of Dietzek A, Goldsmith J, Veith F, Sanchez L, Gupta S, Wengerter K. Interruption of critical aortoiliac collateral circulation during nonvascular operations. J Vasc Surg 1990;12:652-653.
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Kwaan J.H.M., Connolly J.E. Doppler assessment of the inferior epigastric artery flow patterns as a screening test for aortoiliac obstruction. Am J Surg 1979;137:250-251.[Medline]
Accepted for publication July 20, 1999.
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Abstract
Introduction
