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 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.