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 75-year-old male patient known to have diabetes mellitus, hypertension, dyslipidemia, and coronary artery disease underwent coronary artery bypass graft surgery in 2004 left internal mammary artery to left anterior descending artery, saphenous vein graft to right coronary artery and a jump (Y) graft to obtuse marginal 1 and obtuse marginal 2 presented to the emergency department complaining of chest pain and shortness of breath for three days. He was admitted to the coronary care unit as acute coronary syndrome, non-ST elevation MI and started on ACS medication. ECG showed lateral ST-T wave changes and Troponin I was positive, 1.8 ng/ml. The echocardiogram showed moderate hypokinesis of posterlateral wall and the ejection fraction was 50%.\nOn the second day patient underwent a coronary angiogram, which showed a patent saphenous graft to the right coronary artery; patent left internal mammary artery to left anterior descending artery; and patent Y-graft to obtuse marginal 2 and thrombus in the saphenous graft to obtuse marginal 1 [].\nPercutaneous intervention was performed using a manual suction technique with a small pediatric microvena snare catheter 4F (ev3, Plymouth, Minnesota. USA). After manual suction few times the graft become clear [] and both small organized and fresh clots were removed [] and no angioplasty was done in this case. Patient was discharged from the hospital in a very stable condition in a few days.