A 70-year old man was admitted due to resting chest pain. He had undergone coronary artery bypass surgery 6 years ago for multi-vessel disease [left internal mammary artery ( LIMA ) to left anterior descending artery (LAD), saphenous vein graft (SVG) to diagonal branch (D1), SVG to obtuse marginal branch ( OM ), SVG to ramus intermedius (RI) and SVG to posterior descending artery (PDA). His coronary risk factors were hypertension and diabetes mellitus. Echocardiography showed mid-posterior wall hypokinesia with normal ejection fraction. Thallium scan revealed fixed perfusion defects at LAD territory.

Native coronary artery showed total occlusion at middle LAD, diffuse stenosis at left circumflex artery (LCX), and total occlusion at distal right coronary artery (RCA). LIMA to LAD, SVG to D1 and SVT to OM were patent, but SVG to RI was not visualized, which imply a total occlusion. Also, discrete and severe narrowing was noted in the middle portion of SVG to PDA conduit (Image 1, Image 2).

A 7 F Cordis MPA-1 guiding catheter was engaged into the right SVG ostium. A 0.014 inch filter guidewire was used to pass through SVG for embolic protection (Image 3). The SVG was pre-dilated with a Sprinter balloon (3.0 x 15 mm) up to 3.1 mm (10 atm) (Image 4). Angiography showed a significant residual narrowing, implying tight stenosis (Image 5). Then, a Cypher stent (3.0 x 28 mm) was placed at the lesion (Image 6). Because incomplete stent expansion was noted, additional high-pressure balloon dilatation was conducted with a Sprinter balloon (3.0 x 15 mm) up to 3.5 mm (20 atm) (Image 7, Image 8). The final angiogram revealed optimal stent expansion without significant residual narrowing (Image 9, Image 10). Cardiac enzymes remained within the normal range and the patient was discharged two days later.