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 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.