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Ischaemic breast necrosis following coronary artery bypass grafting using left internal mammary artery: understanding
Sandeep B1, Anmol Khanna1, Colin Song1
1Department of Plastic Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia.
Insights
Coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA) can lead to breast necrosis in obese patients with macromastia. Preoperative imaging and informed consent are crucial for managing this risk.
Area of Science:
- Cardiovascular Surgery
- Plastic Surgery
- Surgical Complications
Background:
- Coronary artery bypass grafting (CABG) frequently utilizes the left internal mammary artery (LIMA) for revascularization.
- Sternal wound dehiscence and breast necrosis are rare but serious complications following LIMA harvest.
- This study reports a case and reviews literature on breast necrosis post-CABG, particularly in patients with specific risk factors.
Observation:
- A 55-year-old obese female with macromastia, diabetes, hypertension, and end-stage renal disease developed sternal wound dehiscence and breast necrosis after LIMA harvest.
- A literature review identified 18 cases of breast necrosis post-CABG.
- Affected patients were typically over 50, morbidly obese, had large breasts, and presented with delayed necrosis (≥7 days post-CABG), often in the lower inner quadrant.
Findings:
- Reduced blood supply overlap in large breasts, combined with comorbidities like obesity, diabetes, and renal insufficiency, increases the risk of breast necrosis after LIMA harvest.
- Necrosis characteristically affects the lower inner quadrant of the left breast, including the nipple-areola complex.
- Delayed presentation of necrosis is common, often occurring a week or more after the initial surgery.
Implications:
- Preoperative computed tomography angiography is recommended for patients with macromastia and comorbidities to assess breast vascularity before CABG.
- Informed consent must explicitly address the risk of breast necrosis.
- Surgical reduction or amputation for macromastia may be considered to mitigate risks if LIMA is essential, balancing risks and benefits.
Background:
Coronary artery bypass grafting (CABG) is a common procedure performed commonly using left internal mammary artery (LIMA). We report a case of sternal wound dehiscence and breast necrosis following LIMA harvest in a 55-year-old obese lady with macromastia, diabetes mellitus, hypertension and end stage renal disease requiring dialysis. We also review the existing literature.
Methods:
Publications were identified from Medline All, Web of Science Core Collection, Google Scholar and Cochrane Central Register of Controlled Trial between 1974 and 2 January 2020. We assessed patient co-morbidities, presentation time frame, quadrant of breast necrosis and reconstruction option utilized.
Results:
There were 18 cases of breast necrosis reported post-CABG. The patients were aged 50 or over, morbidly obese and had large tubular breasts. Other risk factors included chronic renal insufficiency, diabetes and hypertension. The presentation was delayed with necrosis only evident 7 days or more after CABG. All the reported cases had necrosis at lower inner quadrant of the left breast with nipple-areola complex.
Conclusion:
Blood supply to the breast is segmental with considerable overlap, however, this overlap is reduced in large breasts. Patients with macromastia and multiple co-morbidities need preoperative imaging (computed tomography angiogram) to evaluate breast vascularity prior to CABG. Risk of breast necrosis needs to be explained during the informed consent. Surgical management of the hypermastia (breast reduction or amputation) may be a factor in facilitating the CABG procedure if indeed the LIMA is absolutely indicated considering the risks and benefits.
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