CASE REPORT

Acute Lower Limb Ischemia After Coronary Artery Bypass Grafting Clémence Le Tanneur, MD,*† Nicolas Mongardon, MD,*† Hakim Haouache, MD,*† Nizar Allouche, MD,‡ Pierre Andrivet, MD,‡ Lauriane Auvergne, MD,† Rabih Houballah, MD,*§ Costin Radu, MD,*¶ and Gilles Dhonneur, MD, PhD*†

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HE INTERNAL MAMMARY ARTERY (IMA) is used as the conduit of choice in coronary artery bypass grafting (CABG) due to its superior long-term outcomes compared to venous grafts.1,2 The IMA collateralizes to the external iliac artery by anastomosis with the inferior epigastric artery. In patients with chronic aortoiliac occlusion, arterial perfusion of the lower limbs may be supplied mostly by this collateral pathway.3,4 In this case report, the authors describe the occurrence of acute bilateral lower limb ischemia following CABG using bilateral IMA grafts in a patient with severe aortoiliac occlusive disease. CASE REPORT A 60-year-old man with stable angina pectoris presented for surgical coronary revascularization. Past medical history was remarkable for recent onset of claudication of his left calf and severe bilateral carotid artery stenosis diagnosed after transient ischemic attack. Critical stenosis of the right carotid artery required revascularization by angioplasty and stenting, which occurred 2 months prior to presentation. Revascularization of his left carotid artery was postponed due to evidence of severe triple-vessel disease on coronary angiogram with preserved left ventricular function. The patient’s chronic medications included dual antiplatelet therapy, and clopidogrel was stopped 5 days prior to surgery. Under standard anesthetic management, sternotomy followed by left and right IMA harvesting were performed; both arteries were notable for large diameters of approximately 6 millimeters. The patient’s CABG was completed uneventfully. In the intensive care unit, norepinephrine was weaned within 6 hours, prophylactic anticoagulation was initiated, and the patient was extubated shortly afterwards. Eighteen hours after surgery, the patient complained of acute pain in his lower extremities. Physical examination revealed bilateral limb ischemia with disappearance of bilateral femoral artery pulses. CT angiogram demonstrated major atheromatous infiltration of the abdominal aorta, with a 75% reduction of its lumen (Fig 1). The left common iliac artery and the left internal and external iliac arteries were occluded. The left epigastric artery was found to be large and anastomosed with the distal external iliac artery. The right internal iliac artery and the right femoral artery were occluded. The distal arterial vasculature was found to be very thin and irregular bilaterally (Fig 2). Emergent revascularization with bilateral endarterectomies at the bifurcation of the common femoral artery was performed in addition to crossover femorofemoral bypass grafting and angioplasty of the right iliac artery. Despite the use of therapeutic anticoagulation, tissue necrosis appeared a few days later, and the patient required bilateral above-the-knee amputations. Heparin-induced thrombocytopenia was ruled out by the absence of anti-PF4/heparin antibodies. The patient was found to have an ischemic stroke in the entire left middle cerebral artery territory on ICU day 5 after stopping sedation. Numerous

complications, such as ventilator-associated pneumonia, mediastinitis, and pancreatitis, led to withdrawal of care and ultimately death on hospital day 165 due to a massive gastrointestinal bleed. DISCUSSION

In this case report, the authors described the occurrence of acute bilateral lower limb ischemia following CABG in a patient with severe aortoiliac occlusive disease. This complication was precipitated mainly by IMA harvesting and collateral vasculature interruption, which jeopardized bilateral lower limb perfusion. An inflammatory state resulting from major surgery may have further generated a hypercoagulable state, potentially compromising arterial blood flow.5 Chronic aortoiliac occlusive disease induces the development of several collateral arterial pathways: The systemicsystemic pathways (lumbar, intercostal, deep circumflex iliac, internal thoracic, inferior epigastric, and obturator arteries), systemic-visceral pathways (celiac trunk and superior and inferior mesenteric arteries), and other less common pathways (renal or gonadal arteries). The extent of each collateral pathway’s contribution depends on the location and severity of the aortic occlusion and the patency of other possible collateral vessels. The embryonic arterial system development can explain the formation of systemic collateral pathways, such as connections between the IMA and subclavian artery, superiorly, and the IMA and inferior epigastric artery, inferiorly, which then connect to the external iliac artery. This pathway is also known as Winslow’s pathway.6

From the *Université Paris Est, Faculté de Médecine, Créteil, †Service d’Anesthésie et des Réanimations Chirurgicales, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, ‡Service de Réanimation, Centre Hospitalier de Bligny, Briis-sous-Forges, §Service de Chirurgie Vasculaire, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, ¶Service de Chirurgie Cardiaque, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France. Address reprint requests to Clémence Le Tanneur, MD, Service d’Anesthésie et des Réanimations Chirurgicales, Hôpitaux Universitaires Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France. E-mail: [email protected] © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.10.014 Key word: coronary artery bypass grafting, collateral blood flow, peripheral vascular disease, internal mammary artery, aortoiliac occlusive disease

Journal of Cardiothoracic and Vascular Anesthesia, Vol ], No ] (Month), 2014: pp ]]]–]]]

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LE TANNEUR ET AL

Fig 1. Abdominal computed tomography scan with intravenous contrast on postoperative day 1. This scan demonstrates significant major stenosis of the infrarenal abdominal aorta (arrow).

In patients with chronic aortoiliac occlusive disease, the anastomosis between the IMA and epigastric artery functioned as a collateral in 95% to 100% of patients studied7,8 and was estimated to provide almost 40% of the arterial flow needed to perfuse the lower extremities,8 despite the resistance of these long collateral vessels. To date, only a few reports have underlined this potential complication after CABG, justifying the need to raise awareness about this rare occurrence with potentially critical complications.3,4,9 Specific imaging studies should be discussed for patients with severe peripheral arterial disease undergoing CABG. While systematic IMA angiography is controversial, preoperative IMA angiography is recommended when planning to use an IMA conduit for CABG in patients with chronic aortoiliac occlusive disease.10 Doppler assessment of the inferior epigastric flow also has been proposed7; however, CT angiography of the abdominal aorta and lower extremities remains the modality of choice as it provides information about the entire aorta and collaterals that can be useful for management.6,11 In the unanticipated scenario in which this collateral pathway has not been identified prior to surgery, the finding of a largediameter IMA during the harvesting phase of a CABG procedure should raise the suspicion of a functional collateral vessel with increased blood flow. Grafting the contralateral

Fig 2. Abdominal computed tomography scan with intravenous contrast on postoperative day 1. This scan demonstrates occlusion of the left external iliac artery (short arrow) and a large left inferior epigastric artery (long arrow).

IMA, rather than a radial artery or saphenous vein, could then be carefully considered. The preoperative finding of this collateral pathway offers 3 surgical options, depending on the patient’s risk stratification and case emergency8: (1) In patients with critical aortic stenosis and stable angina pectoris, percutaneous, or surgical revascularization of the aortoiliac occlusion would likely be the best option as a first step since it would allow for the safe completion of CABG with the IMA conduit at a later time. Moreover, the larger diameter of the IMA would allow for technically easier coronary anastomoses. (2) Saphenous vein or radial artery grafting can be used as alternate options to the IMA. In the case of unilateral lower limb arterial blood flow, harvesting the contralateral IMA also can be considered. (3) Simultaneous CABG and aortoiliac revascularization also have been described, especially in young patients requiring optimal patency of arterial grafts.11,12 In cases of major perioperative risk, a multivessel percutaneous revascularization procedure could be performed instead of CABG. In summary, this case report emphasized the importance of identifying collateral pathways that vascularize lower limbs via the IMA in patients with aortoiliac occlusive disease undergoing CABG. Preoperative imaging and optimal planning for surgical revascularization are crucial to avoid acute limb ischemia in this patient population.

REFERENCES 1. Dimitrova KR, Hoffman DM, Geller CM, et al: Arterial grafts protect the native coronary vessels from atherosclerotic disease progression. Ann Thorac Surg 94:475-481, 2012 2. Poston R, Gu J, Brown J, et al: Hypercoagulability affecting early vein graft patency does not exist after off-pump coronary artery bypass. J Cardiothorac Vasc Anesth 19:11-18, 2005 3. Arnold JR, Greenberg JD, Clements S: Internal mammary artery perfusing the Leriche's syndrome. Ann Thorac Surg 69: 1244-1246, 2000 4. Kitamura S, Inoue K, Kawachi K, et al: Lower extremity ischemia secondary to internal thoracic-coronary artery bypass grafting. Ann Thorac Surg 56:157-159, 1993

5. Aronson S, Varon J: Hemodynamic control and clinical outcomes in the perioperative setting. J Cardiothorac Vasc Anesth 25: 509-525, 2011 6. Hardman RL, Lopera JE, Cardan RA, et al: Common and rare collateral pathways in aortoiliac occlusive disease: A pictorial essay. AJR Am J Roentgenol 197:W519-W524, 2011 7. Kim J, Won JY, Park SI, et al: Internal thoracic artery collateral to the external iliac artery in chronic aortoiliac occlusive disease. Korean J Radiol 4:179-183, 2003 8. Yurdakul M, Tola M, Ozdemir E, et al: Internal thoracic arteryinferior epigastric artery as a collateral pathway in aortoiliac occlusive disease. J Vasc Surg 43:707-713, 2006

LOWER LIMB ISCHEMIA AFTER CABG

9. Shalom F, Vunnamadala SP, Gibbs TS: An angiographic consideration prior to coronary bypass graft surgery: Importance of routine selective angiography of the internal mammary artery prior to myocardial revascularization. J Invasive Cardiol 24:E87-E89, 2012 10. Subramaniam B, Singh N, Roscher C, et al: Innovations in treating aortic diseases: The abdominal aorta. J Cardiothorac Vasc Anesth 26:959-965, 2012

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11. Ben-Dor I, Waksman R, Satler LF, et al: A further word of caution before using the internal mammary artery for coronary revascularization in patients with severe peripheral vascular disease! Cathet Cardiovasc Interv 75:195-201, 2010 12. Alexandrescu V, Bergeron P, Perrin R, et al: Combined minimally invasive surgery for coronary bypass and abdominal aortic occlusion. Cardiovasc Surg 8:507-509, 2000

Acute Lower Limb Ischemia After Coronary Artery Bypass Grafting.

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