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[Left internal thoracic artery as a collateral vessel in chronic occlusion of the pelvic artery]
A Farber1, J H Grunert, K Ranke
1Institut für Diagnostische Radiologie, Medizinischen Hochschule Hannover.
Insights
A rare case of Winslow's pathway involving the internal thoracic artery supplying the lower extremities was discovered in a patient with graft failure. This highlights the importance of assessing internal thoracic artery function before coronary bypass surgery.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Anatomical Variations
Background:
- Aorto-bi-iliac grafts are used for treating aortoiliac occlusive disease.
- Post-operative complications can include graft failure and limb ischemia.
- Internal thoracic artery (ITA) is typically used for coronary artery bypass grafting (CABG).
Observation:
- A 53-year-old male presented with severe intermittent claudication 4 years after aorto-bi-iliac graft implantation.
- Transaxillary aortography failed to visualize the left femoral artery.
- Selective angiography identified an unusual collateral pathway (Winslow's pathway) via the ITA to the left external iliac artery.
Findings:
- The left internal thoracic artery served as a critical collateral pathway to the lower extremities.
- This pathway originated from the subclavian artery and supplied the left external iliac artery via superior and inferior epigastric arteries.
- The patient's symptoms were attributed to the compromised flow through this collateral system.
Implications:
- The internal thoracic artery can have significant, previously unrecognized, collateral functions.
- Pre-operative assessment for coronary bypass surgery must exclude ITA's role in lower extremity perfusion.
- This case underscores the need for thorough vascular imaging in patients with peripheral artery disease and prior interventions.
Abstract:
Four years after implantation of an aorto-bi-iliac artery graft, a 53-year-old man suffered from intermittent claudication with a walking distance of 50 meters. By transaxillary aortography the left femoral artery could not be visualized. Selective angiography of the internal thoracic artery revealed a collateral circulation from the subclavian artery via the left internal thoracic artery, the superior epigastric artery and the inferior epigastric artery into the left external iliac artery (Winslow's pathway). Prior to using the internal thoracic artery for coronary bypass surgery, a function of this vessel as a collateral to the lower extremities should be excluded.