Abstract 16128: The Winslow Pathway and Internal Mammary Artery Harvesting in Patients With Aortoiliac Occlusive Disease

Abstract

Introduction We present a case where the left Internal Mammary Artery (IMA) was not a straightforward choice as the grafted vessel in a patient undergoing Coronary Artery Bypass Grafting (CABG). Case Presentation Patient was a 66 years old female with Hypertension, Hyperlipidemia, hypothyroidism, and tobacco use disorder. Evaluation for a motor vehicle accident secondary to a syncopal episode, and intermittent chest tightness over the past few months, showed ST depressions on ambulatory electrocardiographic monitoring, reversible ischemia in the anterior and apical walls on Exercise Stress Test and severe multivessel coronary artery disease involving the distal main left coronary artery and its branches on Coronary Angiography. CABG was advised. Preoperative peripheral angiogram showed bilateral common iliac artery occlusion, precluding IABP placement. Selective angiography of the left IMA showed the left IMA to be the major vessel supplying collateral circulation to the left iliac system. Patient subsequently underwent CABG with bilateral Saphenous Vein Harvest. Discussion IMA harvesting in patients with Aortoiliac Occlusive Disease (AOD) with prominent collaterals through the subclavian-IMA-inferior epigastric-external iliac pathway, AKA the Winslow Pathway (WP), can result in limb threatening ischemia, and elective IMA angiography and/or doppler flow evaluation before CABG can help identify this important collateral pathway. Alternative approaches in patients with AOD include simultaneous coronary and peripheral revascularization, completely avoiding IMA harvesting or in some cases, angioplasty, although there is no consensus thus far.