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Ann Thorac Surg 2003;75:270-271
© 2003 The Society of Thoracic Surgeons

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Case report

Internal mammary artery steal in a dialysis patient

^a Divisions of Cardiovascular Surgery and Nephrology, Toyonaka Municipal Hospital, Osaka, Japan

Accepted for publication August 2, 2002.

* Address reprint requests to Dr Kato, Division of Cardiovascular Surgery, Toyonaka Municipal Hospital, 14-1, 4-chome, Shibahara-cho, Toyonaka, Osaka 560-8565, Japan.

	Abstract

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A 67-year-old man with chronic renal failure who was being treated with dialysis through an arteriovenous fistula in the left arm was scheduled to undergo off-pump coronary artery bypass grafting. Angiography detected the steal phenomenon in the left internal mammary artery during the diastolic phase. Postoperative study with Doppler guidewire showed that the steal of the left internal mammary artery was due to an ipsilateral arteriovenous fistula. Preoperative angiography of the internal mammary artery is therefore recommended for patients on dialysis.

	Introduction

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The internal mamma/ry artery (IMA) is reported to be an excellent graft for dialysis patients [1]. There have been no reports that an arteriovenous fistual could cause ipsilateral IMA steal. We present the case of a 67-year-old patient with IMA steal on the same side as the arteriovenous fistual.

A 67-year-old man was admitted to our hospital with unstable angina on 10 August 2000. He had chronic renal failure and was being treated with dialysis. A side-to-end arteriovenous fistula was constructed in the left wrist on 20 July 1993. Another arteriovenous fistula, the side of the cephalic vein to the side of the brachial artery anastomosis, was constructed in the left antecubital fossa on 12 June 1998 because of dysfunctioning of the former fistula. The coronary angiography demonstrated three-vessel disease and the culprit lesion was thought to be the left anterior descending coronary artery with severe proximal stenosis. On 11 September 2000 angiography of the left IMA demonstrated that the steal occurred during diastole. That is, the antegrade flow of the left IMA was observed during systole and the retrograde flow during diastole without stenosis in the left subclavian artery (Fig 1). On 18 September 2000 the right IMA was grafted to the left anterior descending coronary artery without cardiopulmonary bypass and the postoperative course was uneventful.

View larger version (60K): [in this window] [in a new window]   Fig 1. Angiography of the left internal mammary artery shows steal flow during diastole.

View larger version (105K): [in this window] [in a new window]   Fig 2. The left internal mammary artery flow pattern with the fistula open and occluded. (A) With the fistula open, an antegrade flow was observed during the systolic phase and a retrograde flow was observed during the diastolic phase. (B) With the fistula occluded, the antegrade flow was seen during both phases. (S = systolic phase; D = diastolic phase.)

	Comment

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In the unused IMA the forward flow is observed during both systole and diastole, although mainly during systole. But when this IMA is connected to the left anterior descending artery the diastolic component becomes much larger [2]. Therefore a contralateral IMA or a free IMA graft should be used when the retrograde flow or steal is observed during diastole on preoperative angiography of the IMA on the same side as the arteriovenous fistula.

Judging from the postoperative study with the Doppler guidewire it was obvious that IMA steal was due to the arteriovenous fistula in our case. It is very difficult to measure the flow in an arteriovenous fistula. Frank and colleagues [3] reported that if the blood flow in an arteriovenous fistula is moderate, the increase in cardiac output secondary to the arteriovenous fistula has the same value as the blood flow value. Because in our case the flow volume through the fistula was approximately 1L/min and for optimal management the flow volume through the fistula should be at least within the range of 400 to 600 mL/min [4], the fistula flow in our case may have been slightly high. Our postoperative study did not indicate to what extent fistula flow volume causes ipsilateral IMA steal in patients with dialysis. Preoperative ipsilateral IMA angiography is thus recommended for a patient with an arteriovenous fistula.

	References

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1. Ura M., Sakata R., Nakayama Y., Arai Y., Kitaoka M., Fukui H. The impact of chronic renal failure on atherosclerosis of the internal thoracic arteries. Ann Thorac Surg 2001;71:148-151.[Abstract/Free Full Text]
2. Calafiore A.M., Giammarco G.D., 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]
3. Frank C.W., Wang H.H., Lammerant J., Miller R., Wegria R. An experimental study of the immediate hemodynamic adjustments to acute arteriovenous fistulae of various sizes. J Clin Invest 1955;34:722-731.
4. Oudenhoven L.F., Pattynama P.M., de Roos A., Seeverens H.J., Rebergen S.A., Chang P.C. Magnetic resonance, a new method for measuring blood flow in hemodialysis fistulae. Kidney Int 1994;45:884-889.[Medline]

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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): Hiroshi Kato Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kato, H. Articles by Yokoyama, K. Search for Related Content PubMed PubMed Citation Articles by Kato, H. Articles by Yokoyama, K. Related Collections Coronary disease