First case report of bilateral breast necrosis following coronary artery bypass graft using left internal mammary artery

Abstract

Coronary artery disease (CAD) is one of the most common public health problems worldwide. The overall prevalence of coronary artery disease in Saudi Arabia is 5.5%. 1 Coronary artery bypass graft surgery has gained momentum over the last years effectively treating CAD. Either arteries or veins can be used as conduits for coronary artery bypass graft (CABG) surgery. There are many sites that the conduit can be harvested from, including saphenous vein, left or right internal thoracic artery, radial artery, inferior epigastric artery, right gastroepiploic artery, and splenic artery. 2 The internal thoracic artery, also called internal mammary artery (IMA) graft, is currently the gold standard for myocardial revascularization. It offers long-term patency and provides a long conduit which resists atherosclerosis postimplantation. 3 Internal mammary artery grafts are not detached fully from their original site. IMA graft remains connected to its natural site of origin, and only one end is detached from the chest wall. This end is reattached to the coronary artery intended for the bypass Figure 1(A). 4 IMA gives out multiple vessels at the chest wall that supply the breast, sternum, mediastinum, and thymus. Although the breast is also supplied by the lateral mammary artery and the posterior intercostal branches of the Aorta, Figure 1(B), the IMA compromises the major source of breast vascularization (almost 60%) through the anterior intercostal perforators. 5,6 The harvesting of IMA in CABG procedure is associated with many complications. They are mostly wound related, ranging from skin dehiscence to complete avascular necrosis of the sternum. 7 Ipsilateral breast necrosis following CABG surgery is a rare incident due to the abundant vascularity of the breast and has been sporadically reported in the literature. However, contralateral breast necrosis after CABG procedure had not been reported in the literature up to date.Breast fat necrosis can result from different surgical, pathological, and traumatic causes. It usually presents as a breast lump which can imitate breast cancer. This is especially concerning in elderly patients where a higher probability of both breast cancer and CAD co-exist. The main clinical features of fat necrosis are hard palpable masses with irregular borders. In some cases, they can be tender and associated with skin tethering, bruising,

Left breast necrosis after coronary artery bypass graft surgery

“…[1] There is one case with bilateral breast necrosis reported in the post-CABG period in the current literature. [2] Older patients (>65 years) were more likely to be morbidly obese and had large tubular breasts. Other risk factors for breast necrosis included left internal thoracic artery (LITA) usage for graft, chronic renal insufficiency, diabetes, and hypertension.…”

“…Several breast necrosis were reported in end-stage renal disease patients. [1,2,4] Calciphylaxis (calcific uremic arteriopathy) may cause medial calcification on middle-sized arteries and intimal fibroplasia in end-stage renal disease patients due to imbalance of calcium and phosphate levels. Calciphylaxis may cause extensive skin necrosis in uremic patients.…”