Left internal mammary artery supplying collateral circulation to the epigastric arteries is circumvented with axillofemoral bypass permitting coronary artery bypass grafting and mitral valve repair

Annals of vascular surgery. Brief reports and innovations Pub Date : 2025-09-06 DOI:10.1016/j.avsurg.2025.100405

Brady Antolick , Andrew D. Vogel , Schafer Paladichuk , Melissa Obmann , Christopher Demaioribus , Tyler J. Wallen

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Abstract

Introduction

Aortoiliac occlusive disease (AIOD) is a subset of peripheral artery disease (PAD) characterized by occlusion of the infrarenal aorta and iliac arteries. Patients with AIOD may develop collateral circulation through the internal thoracic artery–inferior epigastric artery (ITA-IEA) pathway to maintain lower extremity perfusion. Coronary artery disease (CAD) often necessitates coronary artery bypass grafting (CABG), where the left internal mammary artery (LIMA) is the preferred conduit for revascularizing the left anterior descending (LAD) artery. In patients with AIOD, disruption of ITA-IEA collaterals during CABG poses a risk of exacerbating lower extremity ischemia.

Case description

We report a case of a 65-year-old female with severe multivessel CAD, mitral valve regurgitation (MVR), and AIOD with ITA-IEA collaterals supplying the lower extremities. Preoperative imaging revealed an occluded distal aorta with inadequate venous conduits. To preserve lower extremity perfusion, the patient underwent axillary-femoral and femoral-femoral bypasses before CABG. A two-vessel CABG was performed using the LIMA to the LAD and the radial artery to the obtuse marginal artery, along with mitral valve replacement. The patient recovered well and was discharged 11 days postoperatively without complications.

Discussion

This case highlights the complexities of managing concurrent AIOD and CAD, emphasizing the importance of preserving collateral circulation. Preoperative imaging enabled strategic surgical planning to balance myocardial revascularization and lower extremity perfusion. The successful use of alternative conduits, such as the radial artery, underscores the necessity of flexibility in graft selection. Multidisciplinary collaboration and individualized surgical planning are crucial in managing patients with AIOD and CAD.

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左乳内动脉为腹壁动脉提供侧支循环，经腋股旁路术绕过，允许冠状动脉旁路移植术和二尖瓣修复

主动脉髂动脉闭塞性疾病（AIOD）是外周动脉疾病（PAD）的一个子集，其特征是肾下主动脉和髂动脉闭塞。AIOD患者可能通过胸内动脉-腹壁下动脉（ITA-IEA）通路发展侧支循环来维持下肢灌注。冠状动脉疾病（CAD）通常需要冠状动脉旁路移植术（CABG），其中左乳内动脉（LIMA）是左前降支（LAD）血管重建的首选管道。在AIOD患者中，CABG期间ITA-IEA侧支的中断有加剧下肢缺血的风险。病例描述我们报告一例65岁女性，患有严重的多血管CAD，二尖瓣反流（MVR）和AIOD，并伴有ITA-IEA侧支供应下肢。术前影像学显示远端主动脉闭塞，静脉导管不足。为了保持下肢血流灌注，患者在CABG前进行了腋窝-股动脉和股动脉旁路手术。使用LIMA到LAD和桡动脉到钝边缘动脉进行双血管冠脉搭桥，同时进行二尖瓣置换术。患者恢复良好，术后11天出院，无并发症。本病例强调了同时处理AIOD和CAD的复杂性，强调了保持侧支循环的重要性。术前影像学检查使有策略的手术计划能够平衡心肌血运重建和下肢灌注。替代导管（如桡动脉）的成功应用强调了移植物选择灵活性的必要性。多学科合作和个体化手术计划是治疗AIOD和CAD患者的关键。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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