A 52-year-old male patient presented to the emergency department with a typical acute chest pain of 1 hour’s duration. The patient was sweaty and anxious on the physical examination and had a systolic blood pressure of 90 mmHg and a diastolic blood pressure of 50 mmHg. Electrocardiography showed ST-segment elevations in DII, DIII, and aVF leads, as well as ST-segment depressions in V1–V3 leads (). His medical history showed double-vessel coronary artery bypass graft surgery (CABG) 2 months earlier due to stable angina pectoris, for which he regularly took diltiazem, acetylsalicylic acid, and atorvastatin. Additionally, there were no cardiovascular risk factors except for family history. The patient’s coronary angiography and bypass reports were, however, not available.\nPrimary PCI was performed based on a diagnosis of acute inferoposterior myocardial infarction within the first hour of chest pain. Coronary angiography showed that the SVG to the right coronary artery (RCA) was occluded with a thrombus (). The left internal mammary artery graft was open and raced with the left anterior descending coronary artery. Additionally, the mid-portion of the circumflex (Cx) obtuse marginalis was 80% stenotic and the Cx and the RCA were totally occluded (Video 1). The lesion on the SVG was passed with a floppy wire and aspirated via manual thrombectomy (Export Catheter, Medtronic Inc., Minneapolis, Minnesota) (). The huge thrombus content was also aspirated (). Tirofiban, a glycoprotein IIb/IIIa inhibitor, at an intracoronary dose of 10 μg/kg was administered. Moreover, severe stenosis was detected in the SVG to RCA anastomosis, and a 2.75×38-mm XIENCE PRO drug-eluting stent (Abbott Vascular, California, USA) was implanted. Post-dilatation with a 3.5×15-mm Emerge NC balloon (Boston Scientific, USA) was performed, and a distal thrombolysis in myocardial infarction (TIMI) flow grade III was provided (/Video 2). An intravenous infusion of 0.15 μg/kg/min of tirofiban was given for 18 hours. After the procedure, the chest pain was relieved and the ST-segment elevation was improved (). The angiographic imaging of the coronary arteries before the surgery was evaluated, and the Syntax Score was calculated to be 30.5 (Video 3). The patient underwent echocardiography, which showed an ejection fraction of 40%, hypokinesia in the inferior and posterior walls, and mild mitral regurgitation. Atorvastatin, nebivolol, prasugrel, acetylsalicylic acid, and ramipril were prescribed, and the patient was discharged without any complications.\nControl angiography and PCI on the 80% mid-portion stenosis of the Cx obtuse marginalis were planned. One month later, a 2.75×24-mm XIENCE PRO drug-eluting stent (Abbott Vascular, California, USA) was implanted in the stenotic region. The stent patency of the SVG to RCA anastomosis was optimal (Video 4). One month later, stress myocardial perfusion scintigraphy was performed and no sign of ischemia was detected. The patient has been followed without any symptoms for 10 months.
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.