title: Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications.
abstract: OBJECTIVE
  To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps.
  
  
  BACKGROUND
  Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise.
  
  
  METHODS
  The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review.
  
  
  RESULTS
  Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces.
  
  
  CONCLUSIONS
  We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG.
authors.affiliation: Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, and Department of Cardiothoracic Surgery, the Royal Melbourne Hospital, Grattan St, Parkville, VIC, 3050, Australia. warrenrozen@hotmail.com
authors.forename: Warren M
authors.initials: WM
authors.lastname: Rozen
authors.forename: Xuan
authors.initials: X
authors.lastname: Ye
authors.forename: Pedro L
authors.initials: PL
authors.lastname: Guio-Aguilar
authors.forename: Alberto
authors.initials: A
authors.lastname: Alonso-Burgos
authors.forename: John
authors.initials: J
authors.lastname: Goldblatt
authors.forename: Mark W
authors.initials: MW
authors.lastname: Ashton
authors.forename: Iain S
authors.initials: IS
authors.lastname: Whitaker
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001940:Breast / Q000098:blood supply; D001943:Breast Neoplasms / Q000453:epidemiology / Q000601:surgery*; D003324:Coronary Artery Disease / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D006801:Humans; D015994:Incidence; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000379:methods* / Q000706:statistics & numerical data; D016462:Mammaplasty / Q000706:statistics & numerical data; D008323:Mammary Arteries / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery; D008866:Microsurgery; D008875:Middle Aged; D011859:Radiography; D014182:Transplantation, Autologous