Our patient was a 78-year-old male presenting for evaluation of acute-onset, anginal chest pain of six-hour duration. The pain was typical of classic anginal chest pain with radiation to the left neck. The patient had an additional complaint of a diffusely edematous, ecchymotic left lower extremity (LLE); however, he was recently post-operative from a left total knee arthroplasty (TKA) four days prior.\nThe patient was maintained on warfarin for a previously identified SVGA with associated thrombus. His warfarin was discontinued three days before the surgery, and an enoxaparin bridge was started instead. The warfarin was restarted on postoperative day one without a bridging strategy at an initial international normalized ratio of 1.1.\nThe patient was previously well with a past medical history notable for three-vessel CABG in 2017 [LIMA to left anterior descending (LAD), SVG to right coronary artery (RCA), and SVG to first diagonal (D1)], SVG-D1 aneurysm with thrombus, thrombocytopenia, essential hypertension, mixed dyslipidemia, New York Heart Association [] class III/American Heart Association class C heart failure with reduced ejection fraction, IgA-kappa monoclonal gammopathy of undetermined significance, and osteoarthritis. In addition to the CABG, the patient had undergone bilateral TKA, Roux-en-Y gastric bypass, and cervical fusion of C4-C6.\nThe patient presented afebrile with stable vital signs: a pulse of 73 beats per minute and blood pressure of 123/57 mmHg, saturating 94% on room air at 18 breaths per minute. On examination, the patient had a prominent S4 gallop and a markedly ecchymotic LLE with 3+ pitting edema to the mid-thigh without jugular venous distension. Initial laboratory findings were remarkable for anemia with a hemoglobin of 6.9 g/dL (baseline 13.5 g/dL), thrombocytopenia to 127 × 103/µL, and an initial high sensitivity troponin of 27 pg/mL.\nFollowing evaluation by emergency department personnel, the patient was placed for admission for suspected non-ST-segment myocardial infarction (NSTEMI) with presenting electrocardiogram shown in Figure .\nThe high-sensitivity troponin increased steadily peaking at 9,632 pg/mL before downtrending. Acute coronary syndrome (ACS) protocols were enacted and the patient was started on a heparin drip. The patient was transfused with packed red blood cells for his anemia. Computed tomography (CT) angiogram of the chest identified known SVG to D1 disease (Figure ) without the presence of pulmonary embolus. The chest pain improved with the therapies and the patient consented to cardiac catheterization.\nCardiac catheterization revealed severe native vessel CAD involving the proximal LAD, proximal RCA, and ostial D1. The bypass grafts were patent, and the distal SVG-D1 anastomosis was aneurysmal with an organized thrombus without significant change compared to March 2016 (Figure ). Post-catheterization diagnosis was suspected distal embolization of a thrombus fragment resulting in branch vessel occlusion resulting from warfarin. The patient tolerated the procedure without incident. The remainder of his hospital course was uneventful. He was discharged home in a stable condition on hospital day four on guideline-directed medical therapy for his cardiac ailments.
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.