Selection of Dialysis Patients for Bilateral Internal Thoracic Artery Grafts

Abstract

I enjoyed the recent article by Kai and colleagues [1Kai M. Okabayashi H. Hanyu M. et al.Long-term results of bilateral internal thoracic artery graft in dialysis patients.Ann Thorac Surg. 2007; 83: 1666-1671Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar]. I have concerns using the internal mammary graft in patients with ipsilateral upper extremity arterial venous (AV) fistula. Although no report definitively documents a coronary artery steal with an ipsilateral upper extremity arterial venous fistula, there have been several reports of a coronary steal in this circumstance. In my opinion, coronary steal does not occur during dialysis in a patient status post-coronary artery bypass grafting with an ipsilateral mammary graft if there is average flow through the ipsilateral arteriovenous fistula. However, a coronary steal may exist, particularly in patients who have an extremely high flow AV fistula.My policy has been not to use the internal mammary in patients with extremely high flows through the AV fistula. This can be determined by the flow during dialysis runs.My question for the authors was whether all patients with upper extremity arterial dialysis access received bilateral internal mammaries? Were any patients limited to a single mammary on the contralateral side? Was the type of dialysis (ie, venous catheter, peritoneal, AV fistula) a contributing factor in the decision to use bilateral internal mammaries in this patient population?Assuming bilateral internal thoracic grafts were placed in patients with upper extremity AV fistulae, was coronary ischemia noted any more frequently in the coronary distribution perfused by the ipsilateral mammary as compared with the contralateral mammary? I enjoyed the recent article by Kai and colleagues [1Kai M. Okabayashi H. Hanyu M. et al.Long-term results of bilateral internal thoracic artery graft in dialysis patients.Ann Thorac Surg. 2007; 83: 1666-1671Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar]. I have concerns using the internal mammary graft in patients with ipsilateral upper extremity arterial venous (AV) fistula. Although no report definitively documents a coronary artery steal with an ipsilateral upper extremity arterial venous fistula, there have been several reports of a coronary steal in this circumstance. In my opinion, coronary steal does not occur during dialysis in a patient status post-coronary artery bypass grafting with an ipsilateral mammary graft if there is average flow through the ipsilateral arteriovenous fistula. However, a coronary steal may exist, particularly in patients who have an extremely high flow AV fistula. My policy has been not to use the internal mammary in patients with extremely high flows through the AV fistula. This can be determined by the flow during dialysis runs. My question for the authors was whether all patients with upper extremity arterial dialysis access received bilateral internal mammaries? Were any patients limited to a single mammary on the contralateral side? Was the type of dialysis (ie, venous catheter, peritoneal, AV fistula) a contributing factor in the decision to use bilateral internal mammaries in this patient population? Assuming bilateral internal thoracic grafts were placed in patients with upper extremity AV fistulae, was coronary ischemia noted any more frequently in the coronary distribution perfused by the ipsilateral mammary as compared with the contralateral mammary?