Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Nov 26, 2019; 11(11): 277-281
Published online Nov 26, 2019. doi: 10.4330/wjc.v11.i11.277
Management of atherosclerotic plaque in left internal mammary artery graft five years after angiographic patency: A case report
Savvy Nandal, Om Narayan, Peter Barlis, Francis A Ponnuthurai
Savvy Nandal, Om Narayan, Peter Barlis, Francis A Ponnuthurai, Department of Cardiology, The Northern Hospital, Epping, Victoria 3076, Australia
Author contributions: Nandal S wrote the manuscript and reviewed the literature. Ponnuthurai F and Narayan O were patient’s intervention cardiologists. Ponnuthurai F, Narayan O and Barlis P reviewed the literature and revised the final version of the manuscript. All authors issued final approval for the version to be submitted.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016). The guidelines of the CARE Checklist (2016) have been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Savvy Nandal, MBBS, Research Associate, Department of Cardiology, The Northern Hospital, 185 Cooper Street, Epping, Victoria 3076, Australia. savvy.nandal@nh.org.aa
Telephone: +61-38-4058000 Fax: +61-38-4058405
Received: May 30, 2019
Peer-review started: June 4, 2019
First decision: August 2, 2019
Revised: August 9, 2019
Accepted: October 7, 2019
Article in press: October 7, 2019
Published online: November 26, 2019
Processing time: 176 Days and 0.3 Hours
Abstract
BACKGROUND

The left internal mammary artery (LIMA) has demonstrated excellent long-term patency rates when used as a bypass conduit with complications usually occurring in the early postoperative period. The rapid development of de-novo atherosclerosis in a previously non-diseased LIMA, subsequently leading to an acute coronary syndrome (ACS) is rarely encountered.

CASE SUMMARY

A 67-year-old man with history of triple coronary artery bypass graft (8 years ago) presented to our hospital with an ACS. He had undergone angiography 5 years ago to investigate episodic chest pain and imaging of the LIMA at the time did not demonstrate the atherosclerotic process. Emergent angiography demonstrated a severe diffuse stenosis in the proximal to mid segment of the LIMA, with embolization of a moderate sized thrombus to the distal skip segment. The LIMA stenosis was characterised by overlying haziness, consistent with acute plaque rupture, associated with residual luminal thrombus. The patient was managed with antithrombotic therapy to reduce the thrombus burden until repeat angiography after 72 h. At repeat angiography, the thrombus burden was substantially reduced at the distal skip segment as well as at the proximal to mid LIMA with the demonstration of multiple plaque cavities. This lesion was predilated and a 2.75 mm × 33 mm everolimus-eluting stent was implanted to a final diameter of 3.0 mm. The patient made a good clinical recovery and was discharged after 6 d.

CONCLUSION

This case highlights the rapid and late development of atherosclerosis in a graft 5 years after documented patency and the importance for consideration of expectant thrombus management.

Keywords: Left internal mammary artery graft; Atherosclerosis; Thrombus; Case report

Core tip: Late complications of the left internal mammary artery (LIMA) graft occur rarely. We present the case of a 67-year-old man with an acute myocardial infarction due to the rapid progression of atherosclerotic plaque in the mid shaft of the IMA, culminating in plaque rupture and thromboembolism. This case highlights the importance of consideration of expectant thrombus management as well as the importance of considering late complication of LIMA graft as a cause of acute coronary syndrome.