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Ann Thorac Surg 2004;77:379
© 2004 The Society of Thoracic Surgeons

Correspondence

Use of internal mammary artery graft in dialysis patients with upper extremity arteriovenous fistula

Pramod Bonde, MS, FRCS, Gianfranco Campalani, DMS

Department of Cardiac Surgery, Royal Victoria Hospital, Grosevenor Rd, Belfast BT12 6BA, UK

e-mail: prambonde{at}aol.com

To the Editor:

We read with interest the case report by Kato and associates [1] regarding internal mammary artery (IMA) steal in a patient requiring dialysis. We have been using a pedicled IMA graft with the off-pump technique because of its excellent long-term patency and survival benefit. Recently, however, we have adopted a more cautious approach in patients who undergo hemodialysis with an ipsilateral functioning arteriovenous fistula.

Eight months ago, we performed off-pump coronary artery revascularization using a left IMA graft to the left anterior descending coronary artery in addition to saphenous vein grafts to other vessels in a 42-year-old hemodialysis-dependent patient with a functioning left arteriovenous fistula. The postoperative course was uneventful with no complaints of angina. The patient died suddenly on the 14th postoperative day. The biochemical and hematological profiles were normal, and he was receiving no arrythmogenic medication. The postmortem examination revealed that, all grafts were patent and that there were no signs of acute myocardial infarction. This strongly suggested a fatal arrhythmia as the cause of death. In the absence of any explainable reason for the fatal arrhythmia, we suspected IMA steal. Recently there was another report of postoperative angina secondary to the steal phenomenon [2]. Nakayama and associates [3] mentioned one postoperative death due to ventricular fibrillation with no discernible cause in a patient undergoing dialysis who had an IMA graft.

We agree with Kato and co-workers, that IMA steal has implications for the management of patients requiring dialysis. Frequently patients with long-standing chronic renal failure have more than one arteriovenous fistula created, often in both upper extremities with either of the fistulas being nonfunctional or partially functional. In addition, proximal fistulas may have to be made in the future. In such cases, use of a pedicled IMA graft may be contraindicated. Considering the excellent patency associated with the IMA, surgeons have the option of using it as a free graft. This also raises the need to be aware of a possible steal in patients with a functioning IMA–left anterior descending coronary artery graft who have an ipsilateral arteriovenous fistula created after coronary artery bypass grafting.

References

  1. Kato H., Ikawa S., Hayashi A., Yokoyama K. Internal mammary artery steal in a dialysis patient. Ann Thorac Surg 2003;75:270-271.[Abstract/Free Full Text]
  2. Crowley S.D., Butterly D.W., Peter R.H., Schwab S.J. Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fistula. Am J Kidney Dis 2002;40:852-855.[Medline]
  3. Nakayama Y., Sakata R., Ura M., Miyamoto T.-A. Coronary artery bypass grafting in dialysis patients. Ann Thorac Surg 1999;68:1257-1261.[Abstract/Free Full Text]



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