Left internal mammary artery supplying collateral circulation to the epigastric arteries is circumvented with axillofemoral bypass permitting coronary artery bypass grafting and mitral valve repair

• The case demonstrates a novel approach in preserving critical lower extremity perfusion via ITA-IEA collaterals by implementing axillary-femoral and femoral-femoral bypasses before coronary artery bypass grafting (CABG), allowing safe use of the LIMA for coronary revascularization. • Preoperative assessment of collateral circulation and tailored bypass strategies can optimize both cardiac and systemic perfusion, improving patient outcomes. • This case emphasizes the necessity of individualized surgical strategies and close collaboration between cardiac and vascular teams when managing concurrent aortoiliac occlusive disease (AIOD), coronary artery disease (CAD), and valvular pathology. Aortoiliac occlusive disease (AIOD) is a subset of peripheral artery disease (PAD) characterized by occlusion of the infrarenal aorta and iliac arteries. Patients with AIOD may develop collateral circulation through the internal thoracic artery–inferior epigastric artery (ITA-IEA) pathway to maintain lower extremity perfusion. Coronary artery disease (CAD) often necessitates coronary artery bypass grafting (CABG), where the left internal mammary artery (LIMA) is the preferred conduit for revascularizing the left anterior descending (LAD) artery. In patients with AIOD, disruption of ITA-IEA collaterals during CABG poses a risk of exacerbating lower extremity ischemia. We report a case of a 65-year-old female with severe multivessel CAD, mitral valve regurgitation (MVR), and AIOD with ITA-IEA collaterals supplying the lower extremities. Preoperative imaging revealed an occluded distal aorta with inadequate venous conduits. To preserve lower extremity perfusion, the patient underwent axillary-femoral and femoral-femoral bypasses before CABG. A two-vessel CABG was performed using the LIMA to the LAD and the radial artery to the obtuse marginal artery, along with mitral valve replacement. The patient recovered well and was discharged 11 days postoperatively without complications. This case highlights the complexities of managing concurrent AIOD and CAD, emphasizing the importance of preserving collateral circulation. Preoperative imaging enabled strategic surgical planning to balance myocardial revascularization and lower extremity perfusion. The successful use of alternative conduits, such as the radial artery, underscores the necessity of flexibility in graft selection. Multidisciplinary collaboration and individualized surgical planning are crucial in managing patients with AIOD and CAD.