Post-Coronary Artery Bypass Grafting Myocardial Ischemia Caused by an Overgrown Left Internal Thoracic Artery Side Branch

Eung Re Kim, Se Jin Oh, Hyun-Jae Kang, Ki-Bong Kim
2014 Korean Journal of Thoracic and Cardiovascular Surgery  
We present a patient who developed recurrent angina after coronary artery bypass grafting (CABG). Myocardial single-photon emission computed tomography (SPECT) demonstrated deterioration in the myocardial perfusion, and coronary angiography revealed an overgrown side branch of the grafted left internal thoracic artery (ITA); otherwise, there were no significant changes compared with previous imaging studies obtained after the CABG. After percutaneous embolization of the grafted left ITA side
more » ... ed left ITA side branch, the angina was resolved and myocardial SPECT showed improved perfusion. A 73-year-old man with a history of hypertension and hyperlipidemia presented with dyspnea during exercise and recurrent angina. The patient had undergone off-pump coronary artery bypass grafting (OPCAB) 5 years prior due to unstable angina with 3-vessel disease. The left internal thoracic artery (ITA) was skeletonized as proximally as possible, and all the visible branches were clipped and divided. Then, the right gastroepiploic artery (RGEA) graft was anastomosed to the side of the left ITA in order to construct a Y-composite graft. Thereafter, the left ITA was grafted to the second diagonal (D2) artery and the left anterior descending coronary artery (LAD), and the RGEA was grafted to the first diagonal artery (D1) and the obtuse marginal coronary artery in a sequential manner. On postoperative day 1, a coronary angiography was performed to confirm all patent grafts and good blood flow to the coronary arteries. Outside of that, a side branch of the grafted left ITA, which we were unable to remove because of its proximal branching position, was noticed. At the 1-year postoperative follow-up, an angiography revealed an occluded left ITA-to-LAD anastomosis. Although the patient did not exhibit symptoms of angina, percutaneous coronary stenting of the native LAD was performed to improve the coronary perfusion of the LAD region. Although the patient had been free of angina since the OPCAB, dyspnea on exertion and occasional chest discomfort developed several months before the 5-year follow-up. Myocardial single-photon emission computed tomography (SPECT) showed aggravated resting perfusion of the lateral cardiac wall compared with the 1-year Korean J Thorac Cardiovasc Surg 2014;47:465-467 □ Case Report □ http://dx.
doi:10.5090/kjtcs.47.5.465 fatcat:im6ijlzcpbdrvjejhmb4wibzay