Coexistence of coronary artery disease and severe aortic occlusive disease is reported as 4 to 15% in different series.[7] In this article, we report a case of critical leg ischemia developed soon after an acute myocardial infarction and its rapid and efficient salvage with an AXF bypass surgery is presented.

Figure 1: Aortography revealing the distal aortic occlusive disease.

The patient was prepared for CABG and aorta-distal bypass operation in the cardiovascular intensive care unit. Low-molecular-weight heparin and coronary vasodilator treatment were initiated. During follow-up, the right lower limb demonstrated ischemic signs and symptoms on the following day after CAG. Pain and pallor progressed in a few hours to cyanosis and demarcation line below the right knee was almost settled. Blood gas analyses revealed slight acidosis (pH: 7.27) with compensatory respiratory alkalosis (pCO₂: 23.4). Blood urea nitrogen (BUN) and creatinine levels were increased (46 mg/dL and 1.6 mg/dL, respectively). Hemodynamic variables and cardiac enzyme levels remained high and the overall status of the patient was inconvenient neither for CABG nor aorta-distal revascularization with laparotomy. As a result, an extra-anatomic bypass was planned for the limb salvage. A contrasted computed tomography (CT) was performed to investigate the distal status of the vasculature (Figure 2). Computed tomography showed a distal aortic occlusion and antegrade re-filling of the femoral arteries through the collateral circulation. A right AXF bypass was decided as the best surgical strategy.

Figure 2: Computed tomography showing (a) distal aortic occlusive disease and (b, c) bilateral iliac occlusion.

Under general anesthesia, the right common femoral artery and right subclavian artery were explored. Both were prepared for anastomosis by circumference with elastic vascular tapes. An 8 mm diameter ringed expanded polytetrafluoroethylene (ePTFE) graft was placed subcutaneously through the inserted steel tunneler. A mid-point cutaneous incision was made. The length of the graft was adjusted by trimming the both edges. Proximal part was passed under the pectoralis major muscle. Native arteries were clamped after an intravenous injection of 5,000 IU of unfractionated heparin. Proximal and distal anastomoses were performed with 6-0 polypropylene sutures with an end-to-side manner (Figure 3). Distal femoropopliteal embolectomy was performed before the termination of distal anastomosis. Anastomosed native arteries were de-clamped and de-aired. Circulation was successfully achieved. Intraoperative distal Duplex ultrasound showed triphasic flow pattern of the anterior and posterior tibial arteries. The right brachial artery flow rate was also triphasic and not affected.

Figure 3: Proximal anastomosis of an expanded polytetrafluoroethylene graft to the subclavian artery.

Ischemic signs and symptoms of the right leg were totally regressed and returned to normal. Blood chemistry levels including blood gas analyses reversed to normal levels. The patient was followed for two weeks in hospital during the recovery period. Incision sites were recovered without any complication (Figure 4). Coronary artery bypass graft surgery was, then, performed successfully following cardiac enzymes were dropped to normal levels.

Figure 4: Total recovery of the incision sites (postoperative seventh day).

The simultaneous presentation of coronary artery disease (CAD) and peripheral arterial disease (PAD) are not uncommon. Recent studies have reported the rate of the concomitance about 40%.[7,12] In addition, the coexistence of aortoiliac occlusive was reported 4 to 15% in patients undergoing CABG surgery.[13,14] The concomitance of PAD and CAD usually deserves a combined surgical approach, in which both pathologies are treated at the same session.[7] However, in case of deterioration in the overall status of the patient, procedural priority should be given to the more serious pathology. Briefly, life-threatening manifestation is initially treated and the other pathology is postponed, until the overall condition becomes convenient.[7]

In the presented case, a combined procedure was initially planned; however, the limb ischemia developed instantly and prompt intervention was needed. Thus, an AXF bypass was emergently performed to salvage the right lower limb. Also, CABG operation was postponed due to worsened overall status of the patient. If the combined procedure had been performed, multiple handicaps would have occurred. In addition, STEMI and elevated troponin-T levels, determinant factors of impaired cardiac contractility, would increase the intraoperative mortality. Ischemia period would be elongated due to CABG, leading to irreversible neurological complications such as dropped-foot, or even amputation. In addition, an intraaortic balloon pump insertion would be impossible, while it becomes crucial during CABG surgery. As a result, the strategy was primarily built over the salvage of the leg.

Regarding the etiological progression of our case, what was the reason for the instant appearance of ischemic symptoms soon after the CAG? Although the brachial artery approach was selected for the percutaneous intervention, what caused the distal impairment in tissue perfusion? Was the leg ischemia following a CAG with brachial arterial access merely a coincidence?

In this case, severe occlusive disease affecting the distal aorta and both iliac arteries was considered as the primary pathology. This knife-edge condition was probably maintained, until an unusual physiological status developed. The CAG and the preceding NSTEMI were possibly directly or indirectly responsible for all the ischemic process affecting the right leg. Immobilization during the emergency room, CAG unit and intensive care unit might precipitate the symptoms of distal circulation. An excessive consumption of the radiopaque infusion during the CAG might also precipitate glomerulopathy causing dehydration or overhydration, both of which have the potential to change the hemodynamic variables. A slight increase in BUN levels after CAG might be a predictor of the probable opaque nephropathy which altered the blood composition, as perfusion in the microvascular network can be easily affected by the minute changes in blood rheology.[15]

In conclusion, coexistence of CAD and aortoiliac occlusive disease deserves a unique treatment strategy. Both pathologies can be treated at the same session, either by an endovascular or standard surgical approach. Regarding the surgical treatment, ABF bypass is the golden standard with high patency rates. However, if the laparotomy is unable to be performed due to various reasons, AXF bypass can be easily performed instead. With the evolution of the prosthetic vascular grafts, patency rates of AXF bypass have been also increased. Combined surgery should be considered in eligible patients with a good overall status. Otherwise, more serious pathology should primarily be treated, postponing the other entity to be considered electively.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

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