A hypertensive and diabetic 72-year-old man with 3-vessel CABG surgery, SVG to the first diagonal branch of the left anterior descending artery (LAD) and to the obtuse marginal branch of the left circumflex artery (sequential grafting) and the left internal mammary artery (LIMA) to the distal LAD, performed 25 years earlier, presented at our hospital complaining of recurrent chest tightness over the past week. On physical examination, there were no remarkable findings. An electrocardiography showed a normal sinus rhythm at a rate of 78/min with a complete right bundle branch block, but no significant ST-T change was found compared with the findings of his previous electrocardiography. Regional hypokinesis of the post-lateral wall with moderate left ventricular dysfunction, which had not been previously confirmed, was also observed. Cardiac enzymes were not elevated. Coronary angiography showed the obstruction of SVG with a large thrombus burden (Fig. , Movie 1). Although LAD was chronically occluded from the ostium, there was no significant change compared with his condition 3 years ago. LIMA to LAD was patent, and other natives were the same as they had been 3 years ago. He was diagnosed with unstable angina due to acute SVG thrombosis. Instead of PCI, he was treated with apixaban 5 mg twice a day for 3 weeks in addition to aspirin 100 mg once a day, which was already being taken. We added only apixaban and not a P2Y12 inhibitor considering the high risk of bleeding and the mechanism of thrombotic occlusion. After coronary angiography had been performed and PCI was selected, we planned to load a P2Y12 inhibitor. The angiography 3 weeks after starting apixaban showed a considerable resolution of the thrombus and an opening SVG (Figure , Movie 2). The coronary flow of the final angiography almost reached TIMI grade 3 flow, and there was no significant stenosis in SVG. Therefore, we did not move on to PCI due to the fear of distal embolization. The rest of the patient’s stay in the hospital was uneventful, and he was discharged 1 week after the procedure.
A 49-year-old man presented to our hospital complaining of dull, central chest pain after 1 week of subjective fever. Fourteen years prior to this presentation, the patient underwent coronary artery bypass grafting, and 10 years prior suffered right knee septic arthritis due to Methicillin-sensitive Staphylococcus aureus (MSSA) which was complicated by a mycotic right femoral pseudoaneurysm. The patient had no immunosuppressive medications or medical conditions.\nIn the week prior to presentation, the patient had taken non-steroidal anti-inflammatory drugs for right knee pain after a mechanical injury and had ceased aspirin due to concerns about gastrointestinal haemorrhage. The patient had experienced subjective fevers and knee pain, however, had full range of movement with no tenderness, warmth, or erythaema.\nOn arrival, his electrocardiogram (ECG) showed sinus tachycardia with inferior ST elevation (). Physical examination revealed a blood pressure of 128/88 mmHg, heart rate of 112 b.p.m. and temperature of 36.7°C. Cardiovascular examination was unremarkable and examination of the right knee demonstrated normal range of motion without pain and no effusion. An urgent coronary angiogram was performed demonstrating severe native triple vessel disease, a patent left internal mammary artery graft and an aneurysmal but patent saphenous vein graft from the posterolateral branch to posterior descending branch of the right coronary artery (PDA) (). The Saphenous vein graft skip to the PDA was believed to be the infarct-related artery. No intervention was performed and the patient was managed with aspirin, clopidogrel, beta-blockade, angiotensin receptor antagonist, spironolactone, and intravenous nitrate infusion. Pathology is available in .\nSix hours later, the patient developed fever (38.4°C) with no localizing signs of infection identified; a septic screen was performed. Leucocytosis on the urinalysis led to commencement of IV augmentin (1000 mg + 200 mg QID) and gentamicin (320 mg), which were then changed to flucloxacillin (2 g QID) after blood and urine cultures grew MSSA.\nDue to ongoing chest pain, intervention with covered stents to the aneurysmal graft was considered but decided against because of the persistent bacteraemia and fever. Without revascularization, the patient developed inferior hypokinesis on echocardiogram and Q waves in the inferior leads on ECG. He remained persistently febrile until Day 5 of IV flucloxacillin.\nThere were no other symptoms or signs to suggest another source of infection. The abdomen was soft and non-tender. As MSSA was detected in urine during the initial work up a renal tract US was performed which revealed echogenic kidneys, and the treating cardiology and infectious disease teams attributed this to the systemic sepsis.\nTransthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) showed no evidence of infective endocarditis. Vasculitis and rheumatological screens were negative. Given the strong suspicion of a mycotic aneurysm, a labelled white cell scan was performed on Day 7 post-presentation, which failed to demonstrate an infective focus, or infection within the aneurysm.\nThe patient was discharged on IV flucloxacillin for 6 weeks, and dual antiplatelet therapy with a view to cardiology and infectious disease follow-up for consideration of treatment of aneurysm with percutaneous treatment in the future.\nFour days after discharge, the patient represented with left-sided pleuritic chest pain. Blood cultures were persistently negative. His repeat echocardiogram demonstrated moderately reduced left ventricular (LV) function, with thin walled, akinetic inferior and posterior walls consistent with a completed inferior infarct. The expanding aneurysm of the saphenous vein graft was now visible (on TTE and TOE) as a large pulsatile chamber along the posterior and inferior wall, with flow principally seen in diastole, and compressing the inferoposterior LV wall during diastole consistent with expanding aneurysm of the saphenous vein graft ().\nThe cardiothoracic surgery team performed a redo coronary artery bypass grafting with successful identification and resection of the mycotic aneurysm. Cultures of the operative specimen were negative, though the histological microscopic appearance confirmed the presence of the mycotic aneurysm.\nThe patient’s post-operative recovery was complicated by one admission for management of heart failure, after which he has remained stable and independent in the community as of August 2019. The most recent echocardiograph revealed normal LV systolic function with infarcted inferior and posterior walls, severe left atrial enlargement, and mild mitral regurgitation.