33: Dissection of Both a Left Internal Mammary Graft and the Subclavian Artery

CASE 33 Dissection of Both a Left Internal Mammary Graft and the Subclavian Artery



Michael Ragosta, MD, FACC, FSCAI



Case presentation


A 73-year-old man with a long and complex coronary history presents with increasing angina pectoris over several months. His saga with coronary artery disease began 18 years earlier when he underwent single-vessel bypass graft surgery consisting of a left internal mammary artery to the left anterior descending artery. He developed recurrent angina 8 years ago and was found to have a severe stenosis of the left anterior descending artery distal to the left internal mammary artery anastomosis; the other arteries were without significant narrowing. This lesion was treated with a bare-metal stent with a good clinical result. Over the ensuing years he developed progressive coronary atherosclerotic narrowing of the circumflex and right coronary arteries associated with anginal chest pain, and these were treated with bare-metal stents with a satisfactory clinical result. His last catheterization and intervention occurred 3 years earlier, and he did well until several months ago when he again developed severe angina with minimal exertion. He was referred for cardiac catheterization. In addition to coronary artery disease, he also has a history of diabetes, hypertension, and dyslipidemia.



Cardiac catheterization


An elective diagnostic coronary angiogram found no significant obstructive disease in the right coronary artery. The left internal mammary artery graft was widely patent but there was severe narrowing within the stent placed 8 years earlier (Figure 33-1 and Video 33-1). In addition, there was obstructive narrowing of the left circumflex artery proximal to an old stent (Figure 33-2) and chronic occlusion of the proximal left anterior descending artery. Based on these findings, the operator planned to treat the circumflex lesion and then the in-stent restenosis in the native left anterior descending artery, to be accessed via the left internal mammary artery graft using bivalirudin as the procedural anticoagulant. The circumflex lesion responded well to balloon dilatation followed by placement of a 3.5 mm diameter by 23 mm long everolimus-eluting stent (Figure 33-3).


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FIGURE 33-1 Selective angiography of the left internal mammary artery graft to the left anterior descending artery shows severe stenosis in the left anterior descending artery within an old bare-metal stent (arrow).


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FIGURE 33-2 This left anterior oblique projection with caudal angulation of the left coronary artery shows occlusion of the left anterior descending artery and severe stenosis in the proximal left circumflex artery (arrow).


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FIGURE 33-3 This angiogram was obtained after stenting the circumflex artery (right anterior oblique with caudal angulation).

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Jun 11, 2016 | Posted by in CARDIOLOGY | Comments Off on 33: Dissection of Both a Left Internal Mammary Graft and the Subclavian Artery

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