CASE 29 Acute Vessel Closure During Coronary Intervention

Case presentation

A 57-year-old woman with prior bypass surgery consisting of a left internal mammary graft to the left anterior descending artery and a saphenous vein graft to the right coronary artery presented with the acute onset of prolonged rest chest pain and an elevated troponin I (7.0 ng/mL). In addition to the prior bypass surgery, other important medical history included diabetes, end-stage renal disease treated with hemodialysis, and a prior episode of ventricular tachycardia resulting in implantation of a defibrillator.

Coronary angiography performed at another hospital demonstrated patent bypass grafts but severe disease in the ungrafted ramus intermedius and left circumflex arteries. Initially treated medically, she reported ongoing severe angina and was referred for coronary intervention of the ramus and circumflex arteries.

Cardiac catheterization

Representative angiograms of her left coronary artery are shown in Figures 29-1, 29-2 and Videos 29-1, 29-2. A complex lesion was present in the proximal portion of the ramus intermedius at a bifurcation. The proximal to midsegment of the circumflex was also severely diseased. Importantly, this artery branched from the left main with marked angulation, clearly seen in the left anterior oblique view with caudal angulation (see Figure 29-1).