Ann Thorac Surg 2002;73:1312-1314
© 2002 The Society of Thoracic Surgeons
Case report
Myocardial revascularization with the posterior tibial artery
Vichai Benjacholamas, MD*a,
Sirachai Jindarak, MDa,
Wacin Buddhari, MDa
a Cardiothoracic Unit and Plastic and Reconstruction Unit, Department of Surgery, and Cardiology Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Accepted for publication August 2, 2001.
* Address reprint requests to Dr Benjacholamas, Cardiothoracic Unit, Department of Surgery, Chulalongkorn Hospital, Bangkok 10330, Thailand
e-mail: vichaicu{at}hotmail.com
 |
Abstract
|
|---|
A large number of coronary artery bypass grafts are performed in Thailand. Some patients develop restenosed coronary arteries or stenosed graft conduits. Great saphenous veins, internal thoracic arteries, radial arteries, and right gastroepiploic arteries are used for redo coronary artery bypass grafting. But even with many conduits to choose from, sometimes graft conduits are not available. We report a case of redo coronary artery bypass grafting where the posterior tibial artery was harvested for the graft conduit. Clinical outcome and angiographic results are reported at 1 year postoperation.
|
Introduction
|
|---|
In coronary artery bypass graft surgery, the patency of arterial graft conduits is better than venous graft conduits. The posterior tibial artery has been widely used in plastic and reconstruction surgery with low morbidity but has never been used in coronary artery bypass graft surgery. This graft conduit may be useful when a good graft conduit is lacking. We report here a case of redo CABG with posterior tibial artery graft conduit.
A 64-year-old man had a previous coronary artery bypass graft (CABG) for angina, 8 years prior to presentation. At that time, the left internal thoracic artery was grafted to the left anterior descending artery (LAD). An entire great saphenous vein of the right leg and great saphenous vein of the lower half of the left leg were harvested and used for the graft conduits. He was symptom free for 8 years. During the last 6 months, he developed dyspnea and his New York Heart Association functional class changed from I to III. He underwent a repeat angiography. It showed that the left internal thoracic artery was occluded, the vein graft to the obtuse marginal branch was totally occluded, the vein graft to the posterior descending artery (PDA) was patent, the diagonal and posterolateral branches were stenosed at their origin, and the mid-right coronary artery and proximal PDA were also severely stenosed. The left ventricular function was fair, as the ejection fraction was 0.45.
He was scheduled for redo CABG, and four graft conduits were required. Both radial arteries could not be used for graft conduits because an Allen’s test was positive on both sides. Also, the right gastroepiploic artery could not be used for a graft conduit because of a previous intraabdominal, gastric operation 20 years earlier. The right internal thoracic artery and proximal part of the greater saphenous vein of the left leg were selected for two graft conduits leaving a need for two others. The patient did not have history of diabetes mellitus or claudication of both legs. All distal pulses of both legs were full. Therefore, it was decided to use the left posterior tibial artery for the other two graft conduits.
On May 24, 1999, he underwent redo CABG through the previous median sternotomy wound under cardiopulmonary bypass with moderate hypothermia. Cold blood cardioplegia was infused antegrade via the ascending aorta and retrograde via the coronary sinus. The saphenous vein graft to the PDA was left intact. With moderate hypertrophy of the left ventricle, the right internal artery pedicle could not reach the LAD. Therefore, the right internal thoracic free graft was anastomosed to the LAD distal to the previous anastomosis. A saphenous vein graft was anastomosed to the posterolateral branch. A 23-cm posterior tibial artery was harvested and treated with solution containing heparin, verapamil, and nitroglycerin. The posterior tibial artery was divided into two segments. The longer one was anastomosed to the diagonal branch. The shorter one was anastomosed to the distal right coronary artery, and the proximal part was anastomosed to the new saphenous vein graft in a Y fashion. All other proximal grafts were anastomosed to the ascending aorta.
The postoperative course was uneventful. Low dose of calcium-channel blocker (diltiazem) was used postoperatively. There was no wound infection at the sternum or either leg. The patient could walk well without claudication [1]. At 1 year after operation, he was healthy without symptoms of angina. An angiographic study was performed on him. All grafts were patent with good coronary blood flow (Fig 1).
View larger version (56K):
[in this window]
[in a new window]
|
Fig 1. Angiographic finding: (A) right internal thoracic artery (RITA) free graft from ascending aorta to left anterior descending artery (LAD); (B) posterior tibial artery (PTA) from ascending aorta to diagonal branch (DG); (C) another segment of PTA from saphenous vein graft (SVG; Y graft) to distal right coronary artery (RCA). (PL br = posterolateral branches.)
|
|
|
Comment
|
|---|
Currently, radial and gastroepiploic arteries are widely used. But some patients, such as this one, lack graft conduits for redo CABG, thus another source of conduit must be considered. The inferior epigastric arteries could not be selected because both internal thoracic arteries had already been used. In coronary heart disease patients, approximately 16% are associated with peripheral artery disease [2–3]. The posterior tibial artery has been widely used for vascular flaps in plastic and reconstruction surgery [4–5]. The average length of the posterior tibial artery in Thai people is 28.99 mm and could be used for two grafts [6]. This patient did not have diabetes mellitus and also did not have peripheral vascular disease. Therefore, it was decided to use the posterior tibial artery for this patient. The diameter of this artery is larger than the radial artery. The distal diameter was approximately 2.5 mm, and the proximal diameter was about 3.5 mm. A proximal anastomosis at the ascending aorta is easier when compared with the radial artery.
An angiographic finding at 1 year postoperation demonstrated that the posterior tibial artery grafts were patent with smooth endothelial tissue. The diameter of the posterior tibial artery grafts were reduced in size and equal to the right internal thoracic artery (free graft). Because of only one patient experience, it cannot be concluded whether or not calcium-channel blockers have benefit in posterior tibial artery grafts. At first, we hesitated to use it because this conduit has not previously been used. But after follow-up with clinical and angiographic findings, we believe that this conduit can probably be used in the future, if long-term follow-up demonstrates good function without morbidity of the legs.
|
References
|
|---|
-
Benjacholamas V., Jindarak S. Posterior tibial artery: a new alternative graft conduit for redo coronary artery bypass grafts. Chula Med J 2000;44:277-281.
-
Takita T. Clinical picture and background for progression of peripheral arteriosclerosis in Japanese patients with coronary artery disease. Nippon Ika Daigaku Zasshi 1990;57:147-159.[Medline]
-
Sim E.K., Koo G., Adebo O.A., Lim M.C., Choo M.H., Lee C.N. Prevalence of peripheral artery disease in patients with coronary artery disease. Ann Acad Med Singapore 1993;22:898-900.[Medline]
-
Satoh K., Aoyama R., Onizuka T. Comparative study of reverse flow island flaps in the lower extremities—peroneal, anterior tibial, and posterior tibial island flaps in 25 patients. Ann Plast Surg 1993;30:48-56.[Medline]
-
Li Y.Y., Situ H.Q., Wang J.L., Lu Y. Reconstruction of limb defects with the free posterior tibial artery fasciocutaneous flap. Br J Plast Surg 1994;47:502-504.[Medline]
-
Jindarak S., Khobunsongserm S., Tansatit T. The anatomical basis of fasciocutaneous flap based on the posterior tibial vessels. J Med Assoc Thai 2001;84(Suppl 1):S283-S288.
This article has been cited by other articles:
|
|
|
|
 
M. Winckiewicz, M.-G. Stanisic, R. Szajkowski, and R. Staniszewski
Acute Lower Limb Ischemia in a Young Woman With Arterial Hypoplasia: A Case Report
Angiology,
September 1, 2007;
58(4):
494 - 497.
[Abstract]
[PDF]
|
|
|
Top
Abstract
Introduction
