History

Patient History

A 54-year-old patient was seen at the doctor’s office for chest pain. This patient previously had a quadruple bypass surgery and the physician was concerned about bypass graft occlusion. The patient was referred for a coronary angiography.

Coronary Angiography

A standard cardiac catheterization was performed using a Judkins technique including selective bypass graft angiography.

Saphenous Vein Bypass Graft

The saphenous vein bypass graft to the right coronary artery was subtotaled with very poor flow throughout the entire graft and multiple intraluminal filling defects suggesting thrombus. Minimal outflow into the distal right coronary artery was observed.

The saphenous vein bypass graft to the circumflex obtuse marginal graft was widely patent. Excellent runoff to the obtuse marginal was observed.

A third saphenous vein bypass graft to a diagonal vessel was of normal caliber. Runoff to the diagonal was unimpaired.

LIMA Bypass Graft Angiography

The left internal mammary artery bypass graft was of excellent caliber. The arterial graft was widely patent with excellent runoff.

Selective Native Coronary Arteriography:

The native left coronary was heavily diseased vessel with high-grade stenosis noted in the ostial portion of the left anterior descending coronary artery. The circumflex was also heavily diseased with a total occlusion of the obtuse marginal branch.

The right coronary artery revealed a severe proximal and mid-vessel stenosis with adequate distal vessel caliber.

Conclusion

The saphenous bypass graft to the right coronary artery was not amenable to percutaneous coronary intervention. Successful coronary angioplasty was performed on the native right coronary artery with uncomplicated placement of two coronary stents covering both stenoses.

Computed Tomographic Arteriography of Coronary Bypass Grafts

A SnapShot Segmented retrospective ECG gated Coronary CTA was performed on a LightSpeed Ultra ™multi-slice CT scanner. This study was a follow-up to the Coronary Angiography.

This study was performed as a non-invasive outpatient procedure, which required a bolus injection of 150cc non-ionic contrast material injected into the left antecubital fossa using a 20G IV cannula. Helical scans were obtained from the aortic arch to the apex of the heart using 1.25mm scans covering 15cm of anatomy all under 25 sec.

The CTA study of the bypass graft showed the saphenous vein bypass grafts to the LAD and LCx were widely patent. The third saphenous vein bypass graft to the RCA was subtotaled both proximally and distally. The two stents placed in the native RCA were patent with normal flow.

Images

Curved reformat of the Right Saphenous vein	Right Saphanous cardiac cath view

Post Stent RCA Curved Reformat	Curved reformat of the patient Left Saphenous vein bypass graft to circumflex obtuse marginal

Left saphenous vein bypass graft to diagonal branch	Left saphenous cardiac cath view