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Ann Thorac Surg 2001;71:1401
© 2001 The Society of Thoracic Surgeons
a Service de Chirurgie Cardio-Vasculaire, University Hospital of Liege, C.H.U. du Sart-Tilman, 4000 Liege, Belgium
e-mail: mradermecker{at}chu.ulg.ac.be
To the Editor
The avulsion of the left internal mammary artery (LIMA) 5 days after minimally invasive direct coronary artery bypass surgery (MIDCAB) was reported first in the Annals of Thoracic Surgery in 1997 [1]. McMahon and colleagues reported the case of a 58-year-old man who experienced this dreadful complication after lifting a heavy garbage can on postoperative day 5. An adequate diagnostic workup revealed evolving anterior myocardial infarction due to the occlusion of a previously patent LIMA. At reoperation, the LIMA graft was found to have avulsed 1 cm proximal to the anastomosis. This report prompted the commentary of Fonger [2], who mentioned the "unreported anecdotal incidence of LIMA avulsion in MIDCAB." The possible causes of this complication were recognized as insufficient dissection of the LIMA, interaction between the LIMA and the pericardial edge, adhesion of the conduit to the chest wall, mediastinum, or lungs, with possible susceptibility to traction, linked to movements of the chest wall or displacement of lungs or diaphragm [1, 3].
This complication occurred recently in our 55th case of MIDCAB, a 49-year-old patient referred for surgery after failed PTCA and stenting of the left anterior descending. The operation was conducted through a limited left anterior thoracotomy, with the patient in supine position and with selective lung ventilation. The LIMA was dissected from the sixth intercostal space up to the subclavian vein, using the USSC retractor. Through the fourth intercostal space, the pericardium was opened up 6 to 7 cm in front of the LAD, and the LIMA-to-LAD anastomosis was performed with a running 8-0 Prolene suture under device stabilization and inflow occlusion. The conduit was placed above the pericardium and not tacked to the epicardium. Smooth routing of the conduit during reinsufflation of the lungs was checked.
The patient made an uneventful recovery and was discharged on postoperative day 3.
On postoperative day 13, while doing some stretching exercises, he experienced acute left chest pain and dyspnea. He was readmitted to the hospital, where a diagnostic of left pleural effusion was made. A chest tube was placed and drained 700 ml of old blood. Subsequently, the patient developed anterior myocardial ischemia and collapsed in ventricular fibrillation while in the ICU. Cardiac resuscitation was difficult and the patient was reoperated emergently. The LIMA had avulsed a few millimeters above the anastomosis, which was intact. There was pericardial and left pleural blood effusion. A saphenous vein graft on the LAD was done. The patient made a difficult but eventually complete recovery, despite limited anterior myocardial infarction.
We believe that mobilization of the LIMA and an adequate conduit length are prerequisite to optimal routing of the graft in MIDCAB surgery. This mobilization should enable the conduit to accommodate with slight variations of chest wall amplitude, lungs, or diaphragm excursion. However, no matter what precautions are taken during surgery, this unique situation of the LIMA situated completely in the left chest may expose to secondary displacement of the graft and adhesions with the lungs, mediastinum, or chest wall. In this situation, unexpected adhesions may tackle the conduit and interfere with its capability to accommodate with additional tension produced by the "mobile" neighboring structures, leading to rupture.
Based on our experience and a review of the literature, this complication seems specifically linked to this new technique and its real prevalence should be established. This would eventually lead us to recommend, in addition to adequate mobilization and routing, routine protection of the graft (ie, by pericardial fat pad), or to reconsider the level of postoperative mobilization and exercising in these patients.
References
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