Email this article Progression of chronic lower limb ischemia in a patient with occlusion of the infrarenal aorta after myocardial revascularization using the internal thoracic artery: a clinical case
- Authors: Lar'kov R.N.1, Shilov R.V.1, Sotnikov P.G.1, Zagarov S.S.1, Kolesnikov Y.Y.1, Petrakov K.V.1, Kazanskii M.Y.1, Vishnyakova M.V.1, Nikonov R.Y.1, Mirzemagomedov G.A.1
-
Affiliations:
- Moscow Regional Research and Clinical Institute (MONIKI)
- Issue: Vol 47, No 4 (2019)
- Pages: 370-375
- Section: CLINICAL CASES
- URL: https://almclinmed.ru/jour/article/view/1110
- DOI: https://doi.org/10.18786/2072-0505-2019-47-047
- ID: 1110
Cite item
Full Text
Abstract
Background: The main cause of mortality in patients with atherosclerosis of aorta and peripheral arteries of the lower extremities is ischemic heart disease. The presence of peripheral artery atherosclerosis suggests a high probability of simultaneous coronary involvement. To reduce the risk of cardiac complications, these patients are offered myocardial revascularization as the first step of the intervention; however, the choice of a conduit for coronary artery bypass in these patients remains challenging.
Case report: A 58-year old man with combined coronary artery stenoses, high occlusion of the aorta and common iliac arteries underwent autoarterial myocardial revascularization with the right internal thoracic artery (ITA) and left radial artery ("off pump”). In the early postoperative period, significant progression of the right leg ischemia was observed, related to partitioning of the main collateral flow between the right ITA and the inferior epigastric artery, that had contributed to blood supply to the right lower extremity. Taking into account the lack of efficacy of medical treatment and progression of the leg ischemia, at day 4 postoperatively the patient underwent resection of the infrarenal aorta with aortobifemoral bypass grafting and restoration of blood supply to the lower extremities and resolution of ischemia.
Conclusion: ITA has been recognized as the conduit of choice for surgical treatment of ischemic heart disease; however, its use may result in significant progression of ischemia. When choosing a conduit, ITA at the side of less ischemic lower extremity is preferred. ITA imaging by computed tomography-angiography or by selective ITA angiography can be helpful for assessment of the ITA significance at the side of less ischemic leg. Also, the appearance of retrograde flow in the inferior epigastric artery at Doppler ultrasound examination can be a conditional valuable criterion.
About the authors
R. N. Lar'kov
Moscow Regional Research and Clinical Institute (MONIKI)
Email: fake@neicon.ru
Roman N. Lar'kov - MD, PhD, Head of the Department of Vascular Surgery and Ischemic Heart Disease.
61/2-15 Shchepkina ul., Moscow, 129110 РоссияR. V. Shilov
Moscow Regional Research and Clinical Institute (MONIKI)
Author for correspondence.
Email: shilov.rodion@gmail.com
Rodion V. Shilov - MD, Cardiovascular Surgeon, Department of Vascular Surgery and Ischemic Heart Disease.
61/2-15 Shchepkina ul., Moscow, 129110, Tel.: +7 (495) 684 57 48
РоссияP. G. Sotnikov
Moscow Regional Research and Clinical Institute (MONIKI)
Email: fake@neicon.ru
Pavel G. Sotnikov - MD, PhD, Deputy Chief Physician of Surgery.
61/2-15 Shchepkina ul., Moscow, 129110
РоссияS. S. Zagarov
Moscow Regional Research and Clinical Institute (MONIKI)
Email: fake@neicon.ru
Sergey S. Zagarov - Research Fellow, Department of Vascular Surgery and Ischemic Heart Disease.
61/2-15 Shchepkina ul., Moscow, 129110
РоссияYu. Yu. Kolesnikov
Moscow Regional Research and Clinical Institute (MONIKI)
Email: fake@neicon.ru
Yuriy Yu. Kolesnikov - Junior Research Fellow, Department of Vascular Surgery and Ischemic Heart Disease.
61/2-15 Shchepkina ul., Moscow, 129110
РоссияK. V. Petrakov
Moscow Regional Research and Clinical Institute (MONIKI)
Email: fake@neicon.ru
Konstantin V. Petrakov - Junior Research Fellow, Department of Vascular Surgery and Ischemic Heart Disease.
61/2-15 Shchepkina ul., Moscow, 129110
РоссияM. Yu. Kazanskii
Moscow Regional Research and Clinical Institute (MONIKI)
Email: fake@neicon.ru
Maksim Yu. Kazanskii - Junior Research Fellow, Department of Vascular Surgery and Ischemic Heart Disease.
61/2-15 Shchepkina ul., Moscow, 129110
РоссияM. V. Vishnyakova
Moscow Regional Research and Clinical Institute (MONIKI)
Email: fake@neicon.ru
Marina V. Vishnyakova - MD, PhD, Leading Research Fellow, Department of Diagnostic Radiology.
61/2-15 Shchepkina ul., Moscow, 129110
РоссияR. Yu. Nikonov
Moscow Regional Research and Clinical Institute (MONIKI)
Email: fake@neicon.ru
Roman Yu. Nikonov - MD, Cardiovascular Surgeon, Department of Vascular Surgery and Ischemic Heart Disease.
61/2-15 Shchepkina ul., Moscow, 129110
РоссияG. A. Mirzemagomedov
Moscow Regional Research and Clinical Institute (MONIKI)
Email: fake@neicon.ru
Gadzhi A. Mirzemagomedov - MD, PhD, Cardiovascular Surgeon, Department of Vascular Surgery and Ischemic Heart Disease.
61/2-15 Shchepkina ul., Moscow, 129110
РоссияReferences
- Национальные рекомендации по ведению пациентов с заболеваниями артерий нижних конечностей. Ангиология и сосудистая хирургия. 2013;19(Прилож. 2).
- Дроздов СА. Клиника, диагностика и методы лечения периферического атеросклероза. Трудный пациент. 2005;(10-11):54-8.
- Aboyans V, Ricco JB, Bartelink MEL, Bjorck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Rother J, Sprynger M, Tendera M, Tepe G, Vener-mo M, Vlachopoulos C, Desormais I; ESC Scientific Document Group. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Endorsed by: the European Stroke Organization (ESO), the Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39(9): 763-816. doi: 10.1093/eurheartj/ehx095.
- Paletta CE, Huang DB, Fiore AC, Swartz MT, Rilloraza FL, Gardner JE. Major leg wound complications after saphenous vein harvest for coronary revascularization. Ann Thorac Surg. 2000;70(2):492-7. doi: 10.1016/s0003-4975(00)01414-4.
- Hardman RL, Lopera JE, Cardan RA, Trimmer CK, Josephs SC. Common and rare collateral pathways in aortoiliac occlusive disease: a pictorial essay. AJR Am J Roentgenol. 2011;197(3):W519-24. doi: 10.2214/AJR.10.5896.
- 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(3):179-83. doi: 10.3348/kjr.2003.4.3.179.
- Aboyans V. Polyvascular disease: definition, epidemiology, relevance. In: Lanzer P, editor. PanVascular Medicine, 2nd edition. Berlin: Springer; 2015. p. 4779-810. doi: 10.1007/978-3-642-37393-0_213-1.
- Gallino A, Aboyans V, Diehm C, Cosenti-no F, Stricker H, Falk E, Schouten O, Lekakis J, Amann-Vesti B, Siclari F, Poredos P, Novo S, Brodmann M, Schulte KL, Vlachopoulos C, De Caterina R, Libby P, Baumgartner I; European Society of Cardiology Working Group on Peripheral Circulation. Non-coronary atherosclerosis. Eur Heart J. 2014;35(17):1112-9. doi: 10.1093/eurheartj/ehu071.
- Kristensen SD, Knuuti J, Saraste A, Anker S, B0tker HE, De Hert S, Ford I, Gonzalez Jua-natey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Luescher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Uva MS, Voudris V, Funck-Brentano C; Authors/Task Force Members. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J An-aesthesiol. 2014;31(10):517-73. doi: 10.1097/EJA.0000000000000150.
- Попов ВА. Отзывы экспертов. Хирургическое лечение больных с сочетанием критической ишемии нижних конечностей при поражении аорто-подвздошного сегмента и ишемической болезни сердца. Патология кровообращения и кардиохирургия. 2013;16(1 ):77-8.
- Farooq V, van Klaveren D, Steyerberg EW, Meliga E, Vergouwe Y, Chieffo A, Kap-petein AP, Colombo A, Holmes DR Jr, Mack M, Feldman T, Morice MC, Stahle E, Onuma Y, Morel MA, Garcia-Garcia HM, van Es GA, Dawkins KD, Mohr FW, Serruys PW. Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II. Lancet. 2013;381(9867):639-50. doi: 10.1016/S0140-6736(13)60108-7.
- Leriche R. De la resection du Carrefour aorti-co-l'iliaque avec double sympathectomie lom-baire pour thrombose arteritique de l'aorte: le syndrome de l'obliteration termino-aortique pour arterite. Presse Med. 1940;48:601-15.
- Dietzek AM, Goldsmith J, Veith FJ, Sanchez LA, Gupta SK, Wengerter KR. Interruption of critical aortoiliac collateral circulation during nonvascular operations: a cause of acute limb-threatening ischemia. J Vasc Surg. 1990;12(6):645-51. doi: 10.1067/mva.1990.25254.
- Yurdakul M, Tola M, Ozdemir E, Bayazit M, Cumhur T. Internal thoracic artery-inferior epigastric artery as a collateral pathway in aortoil-iac occlusive disease. J Vasc Surg. 2006;43(4): 707-13. doi: 10.1016/j.jvs.2005.12.042.
- de Heer LM, Buijsrogge MP, Lahpor JR. Acute limb ischemia after internal thoracic artery harvesting: a case report. J Thorac Cardiovasc Surg. 2011;141(1):e5-7. doi: 10.1016/j.jtcvs.2010.09.030.
- Le Tanneur C, Mongardon N, Haouache H, Allouche N, Andrivet P, Auvergne L, Houbal-lah R, Radu C, Dhonneur G. Acute lower limb ischemia after coronary artery bypass grafting. J Cardiothorac Vasc Anesth. 2015;29(6):1624-6. doi: 10.1053/j.jvca.2014.10.014.
- Neufang A, Dorweiler B, Espinola-Klein C, Savvidis S, Doemland M, Schotten S, Vahl CF. Outcomes of complex femorodis-tal sequential autologous vein and biologic prosthesis composite bypass grafts. J Vasc Surg. 2014;60(6):1543-53. doi: 10.1016/j.jvs.2014.07.103.
Supplementary files
