A strange post-CABG presentation Ahmed Shawky Elserafy, M.D. Assistant Professor of Cardiology Ain Shams University

History Mr. HM is a 68 year old single male. Hypertensive for ten years. After accelerating chest pain and a positive stress test; he underwent a coronary angiogram followed by CABG one and a half years ago. After the CABG his chest pain improved. For the past three months; he is now complaining of exertional typical anginal chest pain and left arm pain (radiation of the pain?). He couldn’t complete a stress test because of chest pain so coronary angiography was performed.

Clinical Examination and Investigations Clinically: BP 155/90 mmHg in right UL and 100/70 mmHg in left UL (aortic coarctation, or dissection?). HR= 64 bpm. BMI 22 kg/m². Creatinine: 1.3 mg/dl (creatinine clearance: 58 ml/min). Echo: LVEF 52% with hypokinesia of septum, apex.

RAO caudal view showing retrograde filling of LIMA RAO cranial view showing retrograde filling of LIMA LAO caudal view showing retrograde filling of LIMA Lateral view showing retrograde filling of LIMA

Left radial approach and selective injection of the left subclavian artery with a right Judkin’s catheter shows total occlusion of the left subclavian artery

Terumo® wire not passing even with catheter support Provia® 6 wire not passing even with catheter support

Do we stop? Few further options. Fear of aortic arch injury ± dissection. Fear of perforation with more forceful trials.

Finally, Terumo® wire passed through the occlusion with balloon support

6 x 30 mm balloon inflated several times

Post balloon; still there is a tight fibrotic lesion

8 x 37 mm balloon expandable stent positioned (because of the fibrotic nature of the lesion)

8 x 37 mm balloon expandable stent deployed (showing a tight waist)

FINALLY

Follow Up Take Home Messages Immediately post angioplasty, the blood pressure in both arms equalized. The patient’s chest and left arm pains improved and 6 months later is living a healthy active life. Take Home Messages Patients who underwent CABG should be thoroughly assessed before taking decision for revascularization. When performing an angioplasty, all equipment should be available so as to improve the success rate. Careful assessment of the situation is important to avoid complications when performing angioplasty.