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 48-year-old male presented at our hospital with typical chest pain. His past medical history was unremarkable. His coronary risk factors only included "current smoker". On physical examination, he had a systolic blood pressure of 120 mmHg and a heart rate of 62 beats per minute. An initial electrocardiogram (ECG) showed no definite ST segment change and sinus rhythm (). Initial creatine kinase-MB and cardiac troponin I levels were in the normal range. Transthoracic echocardiography showed no regional wall motion abnormality and normal left ventricular function. We administered aspirin 300 mg for 1 day. CAG revealed a filling defect of the distal left anterior descending artery (dLAD), distal left circumflex artery (dLCX) and LMA (). We decided to aspirate the LMA thrombus and to do PCI at the dLAD and dLCX. A guiding catheter was positioned in the left coronary artery ostium. At that time, he complained of aggravating chest pain. On CAG, the distal region of the 1st diagonal branch (D1) and the obtuse marginal branch (OM) were not visualized (). We thought that this event had developed due to coronary embolization that resulted from the migration of thrombi into the LMA during CAG. Intravascular ultrasonography showed the LMA thrombus (). We tried to aspirate the thrombus in the LMA using a guiding catheter and to do balloon angioplasty in the dLAD and dLCX. Balloon angioplasty was successful only for D1 (). However, the dLAD, dLCX and OM had Thrombolysis In Myocardial Infarction (TIMI) grade 1 flow in spite of repeated balloon angioplasty. Applied platelet glycoprotein IIb/IIIa receptor antagonist (Abcimixab, Reopro®) and balloon angioplasty of the dLAD, OM and dLCX were done sequentially. However, filling defects in the dLAD, OM and dLCX remained ().\nWe cared for the patient in the cardiovascular care unit. Creatine kinase-MB and cardiac troponin I levels were elevated to 349.4 ng/mL and 40.91 ng/mL, respectively. Follow up ECG showed a 3 mm ST segment elevation at leads II, III, aVF and V3-5 after angiography (). We thought that the AMI developed due to distal embolization of the LMA thrombus during angiography. Laboratory profiles associated with hypercoaguability such as lupus anticoagulant, protein C activity 102% (NL 70-130%), protein S activity 74% (NL 73.7-146.3%), D-dimer 0.36 µg/mL (NL 0.0-0.4 µg/mL), antithrombin III 91% (NL 80-120%) and homocysteine 12.2 µmol/L (NL 5.0-15.0 µmol/L) were in the normal range.\nAfter 3 days of intravenous unfractionated heparin (25,000 IU/day), follow-up CAG showed only slight resolution of the filling defect and only in the dLAD, not in the OM and dLCX (). He had no chest pain and was discharged on triple antiplatelet agent. After 1 year of this treatment, he experienced no chest pain and, on follow up CAG, had no significant stenosis or intracoronary filling defects ().