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Ann Thorac Surg 1997;63:1765-1766
© 1997 The Society of Thoracic Surgeons

Case Report

Embolization of IMA Side Branch for Post-CABG Ischemia

Renee S. Hartz, MD, Richard R. Heuser, MD

Illinois Masonic Medical Center, Chicago, Illinois, and Arizona Heart Institute, Phoenix, Arizona

Accepted for publication March 20, 1997.


   Abstract
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Introduction
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The existence of a chest wall "steal" of blood away from the myocardium through patent internal mammary artery branches has been hypothesized as a cause of recurrent angina pectoris after coronary artery bypass grafting. Although some authors believe that such a steal is physiologically impossible because coronary flow occurs in diastole and chest wall flow in systole, we recently documented ischemia in the left anterior descending coronary artery distribution before embolization of a large left internal mammary artery first intercostal branch that had been left intact at the time of operation. After embolization of the branch, clinical and objective evidence of ischemia resolved.


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With the advent of less invasive coronary bypass procedures, many surgeons prefer to harvest only a short length of the internal mammary artery (IMA) to be used as the bypass conduit [1, 2]. This approach has led to increased speculation about the existence of the "steal" syndrome, often invoked as the reason for harvesting the entire IMA with traditional coronary artery bypass grafting. We report the case of a patient who had documented ischemia before embolization of a large left IMA (LIMA) branch, and absence of ischemia afterwards.

See also page 1759.

A 55-year-old diabetic man underwent quadruple coronary artery bypass grafting including bypass of the left anterior descending coronary artery (LAD) with the LIMA. Three months after the procedure he had recurrence of chest pain similar to his preoperative angina. Adenosine-thallium study demonstrated reversible ischemia in the LAD distribution (distal anterior wall, apex, and septum) in addition to a fixed defect in distal anterior wall. Repeat coronary arteriography demonstrated that the vein grafts and LIMA graft to the LAD were patent. The LIMA graft, however, had a large side branch arising within 1 cm of its origin from the left subclavian artery (Fig 1Go). Symptoms persisted and the patient was returned to the catheterization laboratory 2 weeks later for embolization of the side branch. After a 5F IMA diagnostic catheter was used to engage the LIMA, a 0.035-inch Terumo angled guidewire was advanced into the side branch and used to sub-selectively engage the catheter in the artery. With the catheter at least 4 cm into the branch, a 3.0-mm by 20-mm Cook embolization coil was advanced through the catheter. Once the coil was deployed, a second coil was deployed proximal to the first. Occlusion of the branch occurred immediately after placement of the second coil, after which the patient had "excruciating" chest wall pain nothing like his previous chest pain.



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  		Fig 1. . Selective left internal mammary artery angiography demonstrates the presence of a large first intercostal artery that was not divided at the time of coronary artery bypass grafting (arrow).

 
The catheter was withdrawn into the LIMA and angiography showed a widely patent LIMA, successful occlusion of the branch, and improved antegrade flow down the LAD (Fig 2Go). There were no postprocedure electrocardiographic changes and no cardiac enzyme elevations. His chest wall pain was treated with analgesics and resolved within a few hours. He remains free of angina 2 months after the embolization, and repeat thallium-perfusion study demonstrated resolution of the ischemic changes in the anterior wall and septum.



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  		Fig 2. . Repeat angiography after coil embolization demonstrates thrombosis of the proximal portion of the intercostal artery (large arrow). The guidewire is still in place (small arrow).

 

   Comment
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 Comment
References
 
This case is presented not to prove the existence of an IMA steal, but to raise consciousness of the cardiac surgical community about the possibility of its existence. Numerous anecdotal cases exist in which a large side branch has been suspected of causing a steal away from the myocardium [3], but to our knowledge a cause and effect relationship has never been established. We therefore present this well-documented case as an impetus for further study of the entity. In this issue of The Annals, Calafiore's group [4] presented compelling evidence that an IMA steal is unlikely, but did not disprove its existence. Further study is needed to definitively determine whether skeletal muscle in the chest wall can deprive the myocardium of blood flow. If so, the practice of complete harvesting of the IMA for coronary artery bypass grafting should be continued.


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Address reprint requests to Dr Hartz, 836 W Wellington Ave, Chicago, IL 60657 (e-mail: rhartzmd{at}aol.com).


   References
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 References
 

  1. Subramanian V, Stelzer P. Clinical experience with minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135–7.[Abstract/Free Full Text]
  2. Calafiore AM, 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;61:1658–65.[Abstract/Free Full Text]
  3. Ayres RW, Lu CT, Benzuly KH, et al. Transcatheter embolization of an internal mammary artery bypass graft sidebranch causing coronary steal syndrome. Cathet Cardiovasc Diagn 1994;31:301–3.[Medline]
  4. 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;63:1759–64.[Abstract/Free Full Text]

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This Article
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