Floor plan - 2013 Annual Meeting - American Association for Hand ...

End-to-Side Anastomosis to the Internal Mammary Artery in Free Flap Breast Reconstruction:
Preserving the Internal Mammary Artery for Coronary Artery Bypass Grafting
Institution where the work was prepared: Union Memorial Hospital, Baltimore, MD, USA
Amani Hemphill, MD1; Ramon De Jesus, MD2; Nathaniel McElhaney1; Jonathan Ferrari1; (1)Union Memorial Hospital,
(2)Johns Hopkins
Myocardial revascularization has become an indispensable tool in the management of ischemic heart disease over the last four
decades. Because of its long-term patency as compared to venous grafts, the left internal mammary artery (LIMA) graft to left anterior
descending artery has been the gold standard in bypass surgery since the mid 1980s. Additionally, the IMA's location, patency, and
favorable diameter have also lead to its routine use by plastic surgeons as the recipient vessel in microvascular breast reconstruction.
Unfortunately, when the vascular pedicles of breast flaps used for reconstruction are anastomosed to the internal mammary vessels in
an end-to-end fashion, they are rendered too short to reach the coronary artery making them unavailable for future myocardial revascularization.
By anastomosing the flap's vascular pedicle to its internal mammary recipient vessels in an end-to-side fashion, we can preserve
the IMA in its distal course for future myocardial revascularization. We have performed five deep inferior epigastric perforator
(DIEP) flap reconstructions to date using an end-to-side arterial anastomosis without morbidity or mortality. We know cutaneous perforator
flaps develop rich collateral blood supplies which sustain them after their vascular pedicles are disrupted in the setting of debulking
and recontouring. Considering this, should the need arise for coronary artery revascularization in one of our patients, the deep inferior
epigastric pedicle can be safely divided without compromising the viability of the reconstructed breast (DIEP flap). It is foreseeable
that patients who have undergone standard DIEP flap reconstructions may require future coronary artery revascularizations. Because of
this, the preservation of the IMA as a bypass conduit in the manner described is an option that should be widely considered in the context
of free flap breast reconstruction.
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