A 70-year-old woman was presented with new-onset resting chest pain. Her coronary risk factors were diabetes, hypertension and hypercholesterolemia. Echocardiography showed a markedly dilated left ventricular (LV) dimension (end-systolic/diastolic dimension; 60/69mm) with severe LV systolic dysfunction (EF=24%), moderate to severe functional mitral regurgitation and multiple regional wall motion abnormalities.

Coronary angiogram showed severe 3 vessel disease (Figure 1, Figure 2). The patient underwent bypass surgery [left internal mammary artery (LIMA) to left anterior descending artery (LAD), which supplied sequential gastro-epiploic artery (GEA) to posterior descending artery (PDA) and Y-grafted right internal mammary artery (RIMA) to obtuse marginal (OM) branch] (Figure 3, Figure 4). Routine post-operative graft angiogram showed patent all grafts, but massive dissection of LIMA graft was found without significant flow compromise (Figure 5, Figure 6). The surgeon decided to treat medically due to the patient’s poor general condition. However, the patient was admitted via emergency room due to severe exertional chest pain 1 month after surgery. Angiogram showed no significant interval change of dissection in LIMA graft (Figure 7, Figure 8).

After engagement of 7Fr mammary guiding catheter to the ostium of LIMA, 0.014 Runthrough guidewire (Terumo) was carefully advanced to LIMA to GEA graft. At first, cypher (3x13mm) stent was deployed at LIMA to GEA end-to-end anastomosis site, just distal to LIMA-RIMA side-to-end anastomosis site (Figure 9). Just after 1st stent implantation, patient complained severe chest pain and angiogram showed slow flow to both grafts. Second cypher stent (3 x 13mm) was deployed at proximal dissection entry site, but failed to restore the normal flow. After 3rd cypher stent (3x33mm) implantation, graft flow was normalized (Figure 10). Forth cypher stent (3x13mm) was deployed to cover the residual stenosis at LIMA-RIMA anastomosis site (Figure 11). Final angiogram showed good graft flow without significant residual stenosis. Patient was discharged without any complication (Figure 12). Follow-up angiogram at 1-year showed patent all 4 stents without significant restenosis (Figure 13).