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Ann Thorac Surg 2004;77:1135
© 2004 The Society of Thoracic Surgeons

Correspondence

Recommendation for IMA use in dialysis patients with ipsilateral fistula: Reply

Hiroshi Kato, MD, Seiichiro Ikawa, MD

Division of Cardiovascular Surgery, Toyonaka Municipal Hospital, 14-1, 4-Chome, Shibahara-cho, Toyonaka, Osaka 560-8565, Japan

e-mail: h-kato{at}chp.toyonaka.osaka.jp

To the Editor:

We thank Dr Baciewicz for his insightful comments on our case report [1] and read with interest a letter to the editor on this subject [2] by him and Harris. This year at the 67th Annual Scientific Meeting of the Japanese Circulation Society, Satoh and colleagues [3] gave a presentation on the influence of hemodialysis on internal mammary artery (IMA) flow using ultrasound study in patients after coronary artery bypass grafting. They demonstrated that there was no significant change in ipsilateral IMA flow before and during hemodialysis in patients with an arteriovenous fistula in the wrist. Their result is similar to that of your thallium studies during hemodialysis [2]. In our patient, the postoperative study with a Doppler guidewire showed clearly that IMA steal was due to an ipsilateral arteriovenous fistula. The flow volume of the arteriovenous fistula in our patient was approximately 1L/min and lower than that in the patient of Crowley and associates [4]. The optimal flow volume of an arteriovenous fistula is reported to be within the range of 400 to 600 mL/min. We cannot determine exactly to what extent fistula flow volume can cause ipsilateral IMA steal in patients requiring dialysis. If we had used the left IMA as a graft in our patient, myocardial ischemia might have occurred during or immediately after the operation.

We think that an ordinary arteriovenous fistula does not cause an ipsilateral IMA steal. We agree with Crowley and colleagues that both the flow volume and the location of the arteriovenous fistula contribute to myocardial ischemia.

We again recommend that preoperative evaluation of IMA flow using angiography or Doppler study should be performed for dialysis patients who are scheduled to undergo 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. Baciewicz F.A., Jr, Harris R.J. Is "steal" present in hemodialysis patients with ipsilateral internal mammary graft?. Ann Thorac Surg 2002;73:349-350.[Free Full Text]
  3. Satoh H., Uchida E., Nakanishi K., et al. The influence of hemodialysis and av-shunt on bilateral internal thoracic artery flows: an ultrasound study. Jap Cir J 2003;67(Suppl 1):183.
  4. 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]




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