Avulsion of the left internal mammary artery graft after minimally invasive coronary surgery: fatal complication or medical error?

Abstract

Minimally invasive direct coronary artery bypass (MIDCAB) is performed through a left anterior mini-thoracotomy without the use of a cardiopulmonary bypass and offers greater potential for more rapid recovery, reduced pain and a decreased need for blood transfusion than conventional coronary artery bypass grafting. Few major complications of the MIDCAB procedure have been reported in the literature since the first intervention was performed in 1995, but the most serious one is avulsion of the left internal mammary artery (LIMA) graft near the site of anastomosis with the left anterior descending coronary artery. Forensic issues regarding the role of the surgeon in causing this life-threatening emergency condition have not been discussed. We report here the case of a 48-year-old man who died 18 days after a MIDCAB of massive thoracic bleeding due to the avulsion of the LIMA graft. We discuss the probable etiopathogenesis of this fatal complication from a forensic point of view.

Spontaneous Avulsion of Left Internal Mammary Artery Graft a Complication of Coronary Artery Bypass Surgery: Case Report and Review of the literature.

“…Most commonly the avulsion occurs at the site of the anastomosis, however only two of the previously reported cases in addition to our case have reported non-anastomotic avulsion of the conduit [9][10][11]. There are no suggested factors to predict the site of avulsion, however inadequate length of the LIMA graft side by side the tension force excreted by cough in the presence of chronic lung disease are the possible culprits in our case.…”

Successful percutaneous treatment of a catastrophic left internal mammary artery graft avulsion occurring 4 weeks post-coronary artery bypass grafting surgery: a case report

“…As mentioned above, the reported time interval between the conventional CABG operation and the graft avulsion has been very short; 1.5 h 7 and 3 h post-surgery. 6 In MIDCAB setting however the time interval has been variable; as short as 6 h post-operation following closed-chest CPR, 3 13 days post-operation following vigorous stretching exercise, 2 18 days post-operation, 5 and up to 3 months post-operation. 4…”

Perioperative Avulsion of a Left Internal Mammary Artery Graft in a Patient with Syphilis

“…It can have a number of causes. Several authors reported LIMA graft avulsion after MIDCAB [ 8 – 12 ]. Morritt et al reported LIMA graft avulsion 4 hours after conventional CABG surgery occurring at the time of weaning from ventilator [ 13 ].…”