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Year : 2019  |  Volume : 22  |  Issue : 1  |  Page : 96-97
Endovascular approach in chronic aortoiliac disease in patient undergoing coronary artery bypass surgery


1 Department of Cardiothoracic Surgery, General Hospital “G. Papanikolaou,” Thessaloniki, Greece
2 Department of Vascular Surgery, General Hospital “G. Papanikolaou,” Thessaloniki, Greece

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Date of Web Publication14-Jan-2019
 

   Abstract 


Internal thoracic artery (ITA) is an excellent conduit for coronary artery bypass surgery (CABG). We present a patient with known preoperative aortoiliac disease with anterior collateral pathway who had an indication for elective coronary bypass. The use of ITA in these patients may cause lower limb ischemia. Detecting Winslow's anastomotic pathway before CABG is of utmost importance.

Keywords: Aortoiliac disease, collateral blood flow' ischemia, coronary artery bypass surgery

How to cite this article:
Ampatzidou F, Koutsogiannidis CP, Megalopoulos A, Trelopoulos G, Drossos G. Endovascular approach in chronic aortoiliac disease in patient undergoing coronary artery bypass surgery. Ann Card Anaesth 2019;22:96-7

How to cite this URL:
Ampatzidou F, Koutsogiannidis CP, Megalopoulos A, Trelopoulos G, Drossos G. Endovascular approach in chronic aortoiliac disease in patient undergoing coronary artery bypass surgery. Ann Card Anaesth [serial online] 2019 [cited 2019 Apr 20];22:96-7. Available from: http://www.annals.in/text.asp?2019/22/1/96/250198




A 70-year-old male with a recent diagnosis of aortoiliac disease was referred to our department for elective coronary artery bypass surgery (CABG). His computed tomography angiography (CTA) revealed proximal left common iliac artery and proximal right external iliac artery obstruction. In addition, the following collateral pathways were demonstrated: From right subclavian and internal thoracic arteries to right external iliac artery through epigastric arteries and also a greater one at the left side between left internal thoracic artery, which was exceptionally large vessel to left external iliac artery through epigastric arteries, providing total perfusion of the left lower extremity [Figure 1]. Interruption of this collateral flow would cause severe leg ischemia. Endovascular treatment of aortoiliac disease was the first intervention that was decided. Percutaneous endovascular procedure (percutaneous transluminal angioplasty stent) was successfully performed in the left common iliac artery but failed in the right. A month later, a repeated CTA evaluation revealed left iliac artery-femoral axis patency and decreased appearance of left-sided anterior collateral pathway [Figure 2]. Then, he underwent CABG procedure with the use of left internal thoracic artery (ITA) as a conduit to the left anterior descending artery. He had an uneventful postoperative period. He was scheduled for open vascular surgery for the right external iliac artery obstruction.
Figure 1: Collateral pathways

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Figure 2: Left iliac artery-femoral axis patency

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ITA is an excellent conduit for coronary artery bypass.[1] In chronic aortoiliac disease, the development of anastomotic pathways, such as Winslow's collateral, may provide perfusion to the lower extremities. If this is not diagnosed, the use of ITA as a bypass graft may cause lower limb ischemia.[2] Incidence of Winslow's pathway is not well documented. Based on angiographic reports, Winslow's flow is common in cases with severe arterial obstruction (stenosis of >75%).[3] A more detailed imaging investigation could be suggested in severe cases of aortoiliac disease before the decision for ITA use.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bobylev D, Fleissner F, Zhang R, Haverich A, Ismail I. Arterial myocardial revascularization with right internal thoracic artery and epigastric artery in a patient with Leriche's syndrome. J Cardiothorac Surg 2013;8:53.  Back to cited text no. 1
    
2.
Yapici F, Tuygun AG, Tarhan IA, Yilmaz M, Tuygun AK, Yapici N, et al. Limb ischemia due to use of internal thoracic artery in coronary bypass. Asian Cardiovasc Thorac Ann 2002;10:254-5.  Back to cited text no. 2
    
3.
Kim J, Won JY, Park SI, Lee DY. Internal thoracic artery collateral to the external iliac artery in chronic aortoiliac occlusive disease. Korean J Radiol 2003;4:179-83.  Back to cited text no. 3
    

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Correspondence Address:
Fotini Ampatzidou
Department of Cardiothoracic Surgery, General Hospital “G. Papanikolaou,” Exohi 57010, Thessaloniki
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_60_18

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