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Logo of thijTexas Heart Institute JournalSee also Cardiovascular Diseases Journal in PMCSubscribeSubmissionsTHI Journal Website
Tex Heart Inst J. 2010; 37(2): 254–255.
PMCID: PMC2851423

Inadvertent Anastomosis of Internal Mammary Artery to Great Cardiac Vein

To the Editor:

The recently published article by Puri and associates1 is of great interest. Inadvertent anastomosis of the left internal mammary artery (LIMA) to the great cardiac vein is a rare but important sequela of coronary bypass grafting, previously reported by Starling in 1981.2 In the current case, the patient was treated by placement of a drug-eluting stent to the left anterior descending coronary artery. The stent caused occlusion of the first diagonal coronary artery, but the patient remained asymptomatic.

In some very complex situations, such as when the native artery is severely atherosclerotic or intramyocardial or when the intervention is a redo, placing a coronary artery bypass graft to the target vessel can be impossible. Because the coronary venous circulation is valveless, one can anastomose the LIMA or a reversed saphenous vein graft to the adjacent vein of the target coronary artery.3 After anastomosis, the vein is ligated toward the base of the heart, reversing flow in the vein to achieve myocardial perfusion.3

We have applied this principle on 3 separate occasions when bypass to a target artery was essential but technically impossible. All patients recovered uneventfully without signs of ischemia.

Historically, in cases of inadvertent anastomosis of a conduit to a cardiac vein, treatment has consisted of closure of the fistula and repeat bypass grafting to the target vessel.1 A simpler solution to this problem could be either the open ligation of the draining vein or the percutaneous closure of the fistula via the coronary sinus.4

This timely article by Puri and colleagues reminds us that it is possible to confuse a coronary vein with the corresponding artery, particularly when crystalloid cardioplegic solution is used. If the diagnosis is made on the operating table and the target artery is not found, proximal ligation of the vein is an effective alternative.

Raúl García-Rinaldi, MD, PhD
Héctor Marcano, MD
Mayagüez Medical Center, Ponce School of Medicine, Mayagüez, Puerto Rico


1. Puri R, Dundon BK, Psaltis PJ, Worthley SG, Worthley MI. Inadvertent anastomosis of internal mammary artery to great cardiac vein: a rare complication of coronary artery bypass surgery. Tex Heart Inst J 2009;36(6):626–7. [PMC free article] [PubMed]
2. Starling MR, Groves BM, Frost D, Toon R, Arom KV. Aorto-coronary vein fistula. A complication of coronary artery bypass graft surgery. Chest 1981;79(1):64–8. [PubMed]
3. Park SB, Magovern GJ, Liebler GA, Dixon CM, Begg FR, Fisher DL, et al. Direct selective myocardial revascularization by internal mammary artery-coronary vein anastomosis. J Thorac Cardiovasc Surg 1975;69(1):63–72. [PubMed]
4. Sheiban I, Moretti C, Colangelo S. Iatrogenic left internal mammary artery-coronary vein anastomosis treated with covered stent deployment via retrograde percutaneous coronary sinus approach. Catheter Cardiovasc Interv 2006;68(5):704–7. [PubMed]

Articles from Texas Heart Institute Journal are provided here courtesy of Texas Heart Institute