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 56-year-old Caucasian man presented from an outlying facility 2 h after acute onset of substernal chest pain at rest with diffuse ST segment depression. Sixteen years ago he had triple vessel CABG with two subsequent cardiac catheterization procedures and percutaneous coronary interventions in the last few years.\nOn presentation, the physical examination was unremarkable. Electrocardiogram had shown diffuse ST segment depression. Laboratory data were unremarkable, including cardiac biomarkers. He underwent cardiac catheterization with coronary and SVG angiography. It revealed severe native vessel coronary artery disease with 100% occlusion of all three native vessels. Left internal mammary artery graft to the left anterior descending artery was patent. SVG to right coronary artery (RCA) angiography revealed two aneurysms, one in the mid-body of the vein graft measuring 3 cm, followed by another 5 cm large aneurysm at the distal segment []. There appeared to be a leak of the contrast into the right atrium (RA) from the distal aneurysm. The aneurysm also had a posterior descending artery (PDA) runoff through the prior placed stent to the PDA at the anastomosis.\nThe patient was hemodynamically stable and reviewing the coronary anatomy we did not find any lesions that were amenable to intervention. He was monitored on the cardiac floor and had further imaging studies for better visualization of the SVG leak. A poorly defined right atrial mass was also appreciated in the subcostal view of the transthoracic echocardiogram for which he underwent a transesophageal echocardiogram (TEE). TEE revealed the aneurysm measuring 5.0 cm × 5.3 cm with Doppler flow within and extending from the structure into the RA []. A chest computed tomographic scan with contrast revealed a partially thrombosed aneurysm measuring 2.8 cm × 3.0 cm about 3.4 cm distal to the RCA graft origin and a large aneurysm measuring 5.0 cm × 4.2 cm distal to the first aneurysm both in the SVG to the RCA. The aneurysm also demonstrated a fistulous connection to the RA [ and ].\nThe cardiovascular surgical consultation was requested regarding further management options given the above findings. Percutaneous treatment including covered stent placement across the aneurysmal segments of the SVG was discussed. After a thorough discussion with the patient, he decided conservative management at the point.