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A 50 year old man with a history of familial hypercholesterolaemia was admitted because of bilateral intermittent claudication of both legs and chest pain. An abdominal aortogram revealed total occlusion of the infrarenal aorta (below). Cardiac catheterisation revealed severe triple vessel disease with normal left ventricular function. Selective angiography of the bilateral internal thoracic arteries documented rich anastomoses between the superior and inferior epigastric arteries with retrograde flow to the ipsilateral external iliac arteries (Winslow's pathway) (right). In this case, these findings were especially important in order to avoid the risk of acutely ischaemic limbs, because the internal thoracic arteries would have been used for coronary artery bypass grafting. Both aorto-bifemoral grafting and coronary artery bypass grafting using bilateral internal mammary arteries and left radial artery were simultaneously undergone without complication.
