We read with great interest the article by Currie et al. [1] regarding the feasibility of using the internal thoracic artery for coronary artery bypass grafting (CABG) and for breast reconstruction. The authors concluded that a skeletonised left internal thoracic artery harvested at the fourth intercostal space can reach the target vessel in the majority of cases; therefore CABG using the left internal thoracic artery is feasible in women with left breast reconstruction by an autologous flap with pedicles anastomosed to internal thoracic vessels.
The internal thoracic vessels are considered as the first-choice donor vessels for microvascular breast reconstruction, and the selection of adequate recipient vessels is of utmost importance for a successful microsurgical result. Many surgeons have designated the internal thoracic vessels as the pedicle of choice especially in cases of delayed breast reconstruction because this approach requires harvesting a shorter pedicle, avoids axillary scaring and decreases postoperative shoulder discomfort [2-3]. Exposure of internal thoracic vessels is technically challenging, it requires removal of a portion of the third rib and scrupulous technique when preparing the vein. The veins can be very fragile thus rendering the outflow inadequate, on the other hand, the venous anatomy is unpredictable and represents one major drawback of this technique [3].
The free transverse rectus abdominis musculocutaneous (TRAM) flap is the most commonly used autologous flap in breast reconstruction. It is needless to say that the inferior epigastric vessels are dissected along with the TRAM flap [2]. To reduce the possibility of the loss of the autologous flap after CABG, one should not use the left TRAM flap to reconstruct the left breast. Reverse blood flow in the internal thoracic artery depends on musculophrenic artery and superior epigastric artery, the latter one depends mainly on the inferior epigastric artery [4].
We recommend using the right TRAM flap or other flaps such as gluteal flap when considering reconstruction of the left breast in women with an increased risk of cardiovascular disease. We also agree with Al-Benna et al., who advocate warning patients against the potential loss of the internal thoracic artery for CABG in a consent form before free flap breast reconstruction [5].
Conflict of interest: none declared.
References
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