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Ann Thorac Surg 2001;71:1681-1682
© 2001 The Society of Thoracic Surgeons

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Case report

Successful VATS ligation of a large anomalous branch producing IMA steal syndrome after MIDCAB

^a Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky, USA
^b Division of Cardiology, T. J. Sampson Hospital, Glasgow, Kentucky, USA

Accepted for publication June 4, 2000.

Address reprint request to Dr Bousamra, Division of Thoracic and Cardiovascular Surgery, Jewish Hospital and the University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY 40202
e-mail: bousamra{at}louisville.edu

	Abstract

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The occurrence of a flow "steal phenomenon" from a large branch of the internal mammary artery (IMA) is rare and its pathogenesis is still controversial. We describe a case of a patent large anomalous left IMA branch which produced recurrent angina 3 years post MIDCAB. Transcatheter coil obliteration of the vessel produced symptomatic relief. However, six months later, chest pains recurred in association with unwinding of the coil and recannulization of the collateral vessel. Successful ligation of the culprit branch using a VATS approach is presented.

	Introduction

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The MIDCAB has become an accepted less invasive surgical modality for the treatment of a subgroup of patients with coronary artery disease [1]. This direct approach, however, allows for only the harvest of the mid to distal internal mammary artery (IMA), leaving the more proximal branches of the conduit available for collateral flow away from the coronary bed. Few reports have described the IMA flow steal phenomenon after coronary bypass, either by the standard CABG or newer techniques [2–4] and its occurrence has been attributed to an incomplete IMA harvest with symptomatic improvement after obliteration of the collateral circulation.

A 49-year-old diabetic man with post infarction angina and an occluded proximal left anterior descending (LAD) artery underwent a left IMA to LAD bypass through a lateral mini-thoracotomy approach. Symptomatic relief was achieved for 3 years until the development of chest pain on exertion. Coronary arteriography documented a widely patent IMA to LAD anastomosis and the presence of a large lateral branch arising from the IMA at the second intercostal space, that had quick washout of contrast into a proximal intercostal artery. Transcatheter coil embolization was performed and deemed successful, however, 6 months later, the patient had a recurrence of the chest pain. Myocardial ischemia was documented with the finding of a reversible defect in the anterior wall during exercise on a thallium perfusion scan. Repeat angiography showed the failed coiled obliteration of the branch (unwinding of the coil) (Fig 1) and a patent left IMA to LAD anastomosis. A video assisted thoracoscopic (VATS) approach was performed to control the anomalous IMA branch. With the patient in left lateral decubitus and using single lung ventilation, a wedge of 3 cm of the 8th rib at the midaxillary line was resected to allow easier instrumentation on the anterior chest wall and an additional trocar placed at the 5th space in the posterior axillary line for the placement of the 30° angle scope. The vessel was identified emerging from the 2nd intercostal space and meandering laterally under the pleura to feed several large intercostal collaterals. The culprit artery was clipped 3 cm after the lateral end of the coil, and before the first intercostal branch. The postoperative course was uneventful and the patient remains symptom-free 4 months after surgery.

View larger version (94K): [in this window] [in a new window]   Fig 1. Preoperative selective injection of contrast in the left internal mammary artery (IMA) demonstrates a large parallel branch with the unwound coil in the proximal segment, and more distally (arrow) the area ligated at surgery.

	Comment

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In contrast, sporadic case reports speak to its occurrence and is typically described as chest pain on exertion with angiographic identification of the IMA branch and resolution of symptoms after occlusion of the vessel [4]. Hartz and Heuser [8] recently described a case of IMA flow steal with ischemia documented on a thallium study that resolved after coil obliteration both clinically and by the normalization of the nuclear test. In our case, resolution of symptoms were seen transiently after the endovascular procedure until recanalization occurred, with recurrence of pain that later resolved after surgical control of the culprit collateral.

In this patient, the proximity of the medial end of the coil to the main IMA would have put at risk both the IMA and the flow to the LAD, and also the success of the collateral branch obliteration. The use of VATS allowed ligation of the vessel under vision with minimal morbidity and hospital stay.

This case illustrates that IMA flow steal can occur and shows the use of VATS as a valid surgical alternative to control IMA anomalous branches in the occasional patient with a failed endovascular procedure or whenever a repeat angiography represents high risk.

	References

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1. Calafiore A.M., Di Giammarco G., Teodori G., et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
2. Schmid C., Heublein B., Reichelt S., Borst H.G. Steal phenomenon caused by a parallel branch of the internal mammary artery. Ann Thorac Surg 1990;50:463-464.[Abstract]
3. Karamanoukian H.L., D’Ancona G., Salerno T.A., et al. Steal syndrome documented by transit time flow technique in an "H" graft. The Heart Surg For 1999;2:239-240.
4. Nakhjavan F.K., Koolpe H.A., Bruss J., et al. Transcatheter coil occlusion for the treatment of left internal mammary- anterior descending artery steal phenomenon. Cathet Cardiovasc Diagn 1993;28:347-350.[Medline]
5. Luise R., Teodori G., Di Giammarco G., et al. Persistence of mammary artery branches and blood supply to the left anterior descending artery. Ann Thorac Surg 1997;63:1759-1764.[Abstract/Free Full Text]
6. Gaudino M., Serricchio M., Tondi P., et al. Do internal mammary artery side-branches have the potential for haemodynamically significant flow steal?. Eur J Cardiothorac Surg 1999;15:251-255.[Abstract/Free Full Text]
7. Gaudino M., Serricchio M., Glirca F., et al. Steal phenomenon from mammary side branches: when does it occur?. Ann Thorac Surg 1998;66:2056-2062.[Abstract/Free Full Text]
8. Hartz R.S., Heuser R.R. Embolization of IMA side branch for post-CABG ischemia. Ann Thorac Surg 1997;63:1765-1766.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) 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): Michael Bousamra, II Paul A. Spence Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pagni, S. Articles by Spence, P. A. Search for Related Content PubMed PubMed Citation Articles by Pagni, S. Articles by Spence, P. A. Related Collections Coronary disease