A60 year-old male presented with acute ST elevation myocardial infarction. He had undergone coronary artery bypass graft surgery 15 years ago for 3 vessel disease [saphenous vein graft (SVG) to left anterior descending artery (LAD), SVG-left circumflex artery (LCX), SVG-diagonal branch, and SVG-posterolateral branch (PL)]. He had multiple coronary risk factors including cerebrovascular disease, hypertension, and ex-smoking. ECG at admission showed ST elevation at V2-V6, I, aVL.

Left coronary angiogram showed total occlusion at the proximal LAD and LCX (Figure 1-AP caudal, Figure 2-AP cranial). Right coronary artery (RCA) and the SVG to diagonal branch were not visualized, which imply total occlusions. However, the SVG to PL were patent (Figure 3). We had a very difficulty in engaging into the SVG to LAD with right Judkins, left Amplatz, and LCV (left coronary vein graft) catheter (Figure 4-1, Figure 4-2). From aortogram in ascending aorta, we found the ostium of the SVG to LAD (Figure 5). After making curvature at the proximal shaft of the IMA (internal mammary artery) catheter with local heating, we could engage into the ostium of the SVG to LAD. Angiogram of the SVG to LAD showed total occlusion at the distal segment of the SVG and contrast entrapment implying heavy thrombus (Figure 6). After recannalization with 0.014 inch Choice PT wire, predilation with a 2.5?20mm balloon was performed to evaluate the true occlusion segment. Following angiogram revealed that the primary narrowing was located at the anastomosis of the SVG to LAD (Figure 7). Therefore, we decided to treat the lesion with stenting alone after thrombus aspiration with an Export catheter. Distal protection device was not used. However, Reopro was administrated during the procedure. A Taxus stent (3.0?16mm at 12 atm) was deployed first at the anastomosis of the SVG to LAD (Figure 8). Because the SVG was too big to use drug-eluting stent, we put an Express stent (5.0?20mm at 12 atm) at the distal SVG (Figure 9). Fortunately, following angiogram showed TIMI grade 3 flow and optimal stent expansion (Figure 10). She was discharged without procedure-related complications.