Finding the Graft the Hard<br />
Way! An Unusual Case

Dear Editor,

Re-do coronary artery bypass graft (CABG) surgeries are associated with increased peri- and postoperative mortality. The increasing use of these reoperations has led to the use of a variety of different kinds of grafts, e.g., from the left axillary artery or the descending aorta, to reduce the incidence of damage to the patent grafts running near the midline. However, with the increasing number of these patients, there has been a steady rise in the difficulty of assessing these grafts when these patients present with acute infarction and limited information is available about their previous surgeries and grafts. We report such a case here and describe an interesting way of dealing with the problem.
Case Report. A 51-year-old Caucasian male with acute inferior ST-elevation myocardial infarction was life-flighted to our hospital and continued to have severe angina despite being administered the appropriate medical therapy. He was taken for emergent cardiac catheterization. The patient had a complicated cardiac history involving original CABG in 1998 followed by multiple angioplasty procedures and a re-do CABG in 1999 at another institution. The details of these procedures were unknown at the time of his presentation at our center.
Diagnostic angiography showed a severe 99% stenosis involving the distal left circumflex artery. A 1.5 x 12 mm Voyager balloon (Abbott Vascular, Santa Clara, California) was advanced to the area of stenosis over a 0.014 inch extra support wire and was inflated to 10 atm. Distal flow improved, but 50% stenosis persisted even after multiple inflations. The saphenous vein graft to the circumflex artery was considered the acute lesion because of the persistent dye stain in the graft. However, the origin of the graft could not be found, even after repeated attempts. The graft was filling retrogradely off the native circumflex artery, therefore the 0.014 inch extra support wire was used to pass retrogradely into the graft to the point of total occlusion. A 1.5 x 12 mm Voyager balloon was advanced over the wire and inflated to 15 atm. Passage of the wire into the graft after inflation located the origin of this graft in the descending aorta.
At this point, the right femoral artery was cannulated and a left coronary bypass graft guide was advanced to the origin of the saphenous vein graft in the descending aorta. Dye injection revealed 95% stenosis of the proximal graft (Figure 1). This lesion was then crossed antegradely with a 3.0 x 20 mm Voyager balloon inflated to 12 atm, followed by a 5.0 x 18 mm Multi-Link ULTRA bare-metal stent (Abbott Vascular), which was deployed in the area of stenosis. Final injection showed no stenosis of the graft with excellent distal flow of contrast into the circumflex artery. The patient was in stable condition following the procedure and was discharged home a few days later.
Discussion. Re-do CABG is associated with high perioperative risks, particularly when the patent saphenous vein or internal mammary graft runs near the midline of the sternum and can thus be injured by a median sternotomy and subsequent dissection. In these situations, off-pump bypass grafting from the left axillary artery or descending thoracic aorta via a left thoracotomy approach has proved effective in preventing damage to the other patent grafts.1,2
There have been few reports in the past on catheterization of coronary bypass grafts from the descending aorta.3,4 We report an unusual and successful method of locating the culprit graft by retrograde passage of a wire followed by antegrade stenting. This technique is important in acute infarction patients for whom there is limited information about a previous CABG, especially when strict door-to-balloon time protocols are followed. It should also be noted that most patients with acutely occluded grafts are also found to have complete occlusion of the native vessel proximal to the anastomosis, thus limiting the use of the technique described here.

Ruby Satpathy, MD,
Tom Lanspa, MD, Syed Mohiuddin, MD
Department of Cardiology
Creighton University
Omaha, Nebraska E-mail: ruby.satpathy@cardiac.creighton.edu

References

1. Uppal R, Mills NL, Wechsler AS, Smith PK. Left thoracotomy for reoperative coronary artery bypass procedures. 1993 Update. Ann Thoracic Surg 1993;55:1275–1276.
2. Minakawa M, Takahashi K, Kondo N, et al. Left thoracotomy approach in reoperative off-pump coronary revascularization: Bypass grafting from the left axillary artery or descending thoracic aorta. Jpn J Thorac Cardiovasc Surg 2003;51:582–587.
3. Bilazarian SD, Shemin RJ, Mills RM. Catheterization of coronary artery bypass graft from the descending aorta. Cathet Cardiovasc Diagn 1990; 21:103–105.
4. Kobayashi Y, Al-Mubarak N, Moses JW. Percutaneous coronary intervention in a sequential radial artery graft anastomosed to the descending aorta, left circumflex artery and obtuse marginal artery. J Invasive Cardiol 2002;14:642–644.