LETTER

Reply to Letter: The Benefits of Internal Thoracic ArteryCatheterization in Patients with Chronic Abdominal AorticOcclusion

Nikola Ilic • Lazar Davidovic • Igor Koncar •

Marko Dragas • Markovic Miroslav •

Colic Momcilo • Ilijas Cinara

Published online: 7 December 2011

� Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2011

To the Editor: We appreciate our colleagues’ interest in our

article [1]. However, in our opinion, their remarks are not

fully justified.

The purpose of our study was to evaluate potential

benefits and capabilities of internal thoracic artery (ITA) as

a collateral pathway in patients with chronic aortic occlu-

sion by comparing runoff visualization with group of

patients who underwent classic transaxillary aortography.

By no means did we intend to prove that this approach is

the best way to visualize distal runoff, and we did not state

this in our article.

There are two general anatomic systems of collateral

vessels that develop in response to the gradual occlusion

of the abdominal aorta. The viscerosystemic collateral

network is made of superior and inferior mesenteric

arteries as well as hypogastric arteries. The Winslow

collateral pathway is the part of systemic–systemic net-

work dominant mainly in juxtarenal aortic occlusions and

presents an anastomotic network between superior and

inferior epigastric artery. Depending on the dominant

collateral network in a particular patient, runoff visuali-

zation should be managed individually, and that is what

we usually do. In cases where superior mesenteric artery

is dominant, supraceliac aortography would be sufficient

for distal runoff visualization. In most cases, however,

classic transaxillary aortography with the tip of the

catheter slightly above the renal arteries would be ade-

quate. However, in a small group of patients, where the

Winslow collateral pathway is dominant, these techniques

would be insufficient; ITA catheterization could thus be

useful. In this particular situation, the high aortic arch

aortography proposed by our colleagues would fail to give

satisfactory runoff opacification because ITA would be

avoided.

Further, we must disagree with our colleagues that the

visualization of the common femoral artery provided in

their Fig. 1B especially on the left side, is better than one

we provided in our article. Their image lacks opacifica-

tion, especially of the deep femoral artery, which is

crucial for the surgeon contemplating a bypass proce-

dure. Furthermore, the collateral pathway shown in the

image is more likely to be from high intercostals and

from the deep circumflex ilium artery branch of the

external iliac artery and not from the epigastric inferior

artery, as they have mentioned. Theoretically, it could

not be possible.

We would be interested if our colleagues could publish

their results and observations in a more extensive group of

patients.

We agree that the right axillary approach could increase

aortic arch embolization; however, we had no such expe-

rience. On the other hand, we do not see the reason for

intravenous digital subtraction angiography if multislice

computed tomography is available. We suppose that the

N. Ilic (&) � L. Davidovic � I. Koncar � M. Dragas �M. Miroslav � C. Momcilo � I. Cinara

Clinical Center of Serbia, Clinic of Vascular Surgery and

Endovascular Surgery, 8 K. Todorovica st, 11000 Belgrade,

Serbia

e-mail: fosafosa75@yahoo.com

N. Ilic � L. Davidovic � M. Dragas � M. Miroslav

Medicine Faculty, University of Belgrade, Belgrade, Serbia

123

Cardiovasc Intervent Radiol (2012) 35:217–218

DOI 10.1007/s00270-011-0309-5

risk of deep vein thrombosis and pulmonary embolism in

that situation would be as same or similar as the risk of an

embolic event during aortic arch manipulation.

Conflict of interest None

Reference

1. Ilic N, Davidovic L, Koncar I, Dragas M et al (2011) The benefits of

internal thoracic artery catheterization in patients with chronic

abdominal aortic occlusion. Cardiovasc Intervent Radiol 34:396–400

218 N. Ilic et al.: Chronic Abdominal Aortic Occlusion

123