Necrosis of the Anterior Abdominal Wall after Harvest of both Internal Thoracic Arteries and Inferior Epigastric Arteries

Abstract

Introduction: The internal thoracic artery (ITA) and inferior epigastric artery (IEA) may be used as conduits for myocardial revascularization. ITA grafts are currently the gold standard for myocardial revascularization. The ITA provides a long conduit that resists atherosclerosis after implantation and offers long-term patency. Experience with IEA grafts remains limited due to their short length and greater variation in size and anatomy; IEAs are primarily used as Y-grafts from another arterial conduit. Therefore, harvesting bilateral ITAs and IEAs is rare. Harvesting the ITAs and IEAs potentially can lead to hypoperfusion of the adjacent abdominal wall. Clinical data were prospectively collected on our patients who had had ITA and IEA harvest for myocardial revascularization to determine the dimensions of the associated risk to the abdominal wall, particularly the incidence of clinically significant abdominal wall ischemia or necrosis and the extent of tissue loss. Methods: We created a prospective database from 1990 to 1992 with data from 108 patients receiving myocardial revascularization with at least 1 ITA and at least 1 IEA. Data recorded included age, sex, weight, height and body surface area. Pertinent history was taken, including prior revascularization and the presence of associated medical diseases. The harvesting procedure was similar in all patients. Myocardial revascularization was performed and patients were followed to document the outcomes of these procedures. The incidence of operative death, perioperative myocardial infarction, low cardiac output, and other significant complications were recorded. All tissue necrosis was noted during hospitalization. We defined clinically significant necrosis to be that which required surgical debridement with or without skin grafts. Results: All patients had 1 (84%) or 2 (16%) IEAs harvested. One ITA was harvested in 90% of patients and 82% had both ITAs utilized. All 17 patients in whom 2 IEAs were harvested also had 2 ITAs harvested (16%). Harvesting 2 ITAs and 2 IEAs was based on patient coronary anatomy and the resulting need for additional grafts. The most frequent postoperative complication was supraventricular tachycardia which occurred in 31 patients (28%). Other complications included low cardiac output, renal insufficiency, infections, and death. Only patients who had bilateral ITA and bilateral IEA harvest (N=17) developed abdominal wall tissue necrosis. Of these 17 patients, 2 (12%) had abdominal wall necrosis. The extent of necrosis was typically in an area of about 10 cm in maximum diameter, in the midline between the umbilicus and pubis. The extent of necrosis involved muscle and fascia, but the peritoneum and posterior rectus sheath remained intact in our patients and there was no instance of loss of full thickness of the abdominal wall. The 2 affected patients in our study had bulging of the abdominal wall but no medical intervention was indicated. Conclusions: A small but significant subset of patients have bilateral ITAs utilized for revascularization. While it is rarely necessary, bilateral harvesting of ITAs and IEAs results in about a 10-20% chance of tissue necrosis in the anterior abdominal wall due to ischemia. These data may be most valuable to those who contemplate an abdominal operation in a patient who, for one reason or another, has had one or more of their ITAs or IEAs taken.