Journal of Invasive Cardiology

Case 2. A 49-year-old male presented with unstable angina and was found to have anterior and inferior ischemia on dobutamine stress echocardiography. Two years prior, he had undergone CABG. Coronary angiography through the right femoral artery revealed a proximal LAD occlusion, severe stenosis of the mid circumflex and proximal RCA, an occluded SVG to the right posterolateral branch, a patent SVG to first diagonal, a patent radial graft to the OM1, and a patent LIMA to the LAD (Figure 2A) with a 90% LAD stenosis distal to the LIMA anastomosis (Figure 2B). A decision was made to proceed with multivessel PCI. Anticoagulation was obtained with bivalirudin. The proximal RCA and PDA were stented with a 2.5 x 12 mm and a Xience V 3.0 x 15 mm everolimus-eluting stents (Abbott Vascular) without complications. The LIMA was subsequently engaged with a 90 cm 6 Fr IMA guiding catheter. After a Whisper guidewire (Abott Vascular) was advanced through the LIMA to the distal LAD, the LIMA antegrade flow stopped. Left femoral arterial access was obtained and the SVG to diagonal was engaged with a 6 Fr LCB guiding catheter showing continued LAD filling through the SVG (Figure 2C). PCI of the distal LAD was then performed, delivering equipment through the LIMA guiding catheter and visualizing via injections through the SVG to diagonal branch guiding catheter. The distal LAD lesion was predilated with a 2.0 x 12 mm balloon and successfully stented with a Xience V 2.5 x 12 mm everolimus-eluting stent (Abbott Vascular) (Figure 2D). The LIMA wire was then removed restoring TIMI 3 antegrade flow (Figure 2D). The patient was dismissed the following day and has remained angina-free at 7-month follow up.

Case 3. A 62-year-old male presented with severe exertional angina despite maximal medical therapy. He had undergone CABG 9 years prior to presentation with implantation of a LIMA to mid-LAD, a RIMA-to-RCA, and a SVG-to-diagonal. Angiography revealed significant stenosis of the RCA, the first obtuse marginal and the proximal LAD. The LIMA had a high-grade stenosis at the LAD distal anastomosis (Figure 3A) and was tortuous (Figure 3B). The RIMA-to-RCA and SVG-to-diagonal grafts were both patent. PCI of the LIMA distal anastomotic lesion was planned. Anticoagulation was obtained with unfractionated heparin. The LIMA was engaged with a 90 cm 6 Fr IM guiding catheter and was wired with a Whisper wire, resulting in TIMI 1 antegrade flow (Figure 3C). Contralateral femoral access was obtained and the LMCA was engaged using an XB 3.5 guiding catheter (Figure 3D), allowing visualization of the LIMA-LAD anastomosis. The lesion was predilated (via the IM guiding catheter) with a 2.0 x 12 mm and a 2.5 x 20 mm balloon and stented with an Xience V 2.5 x 23 mm everolimus-eluting stent. Following removal of the Whisper wire, the distal LIMA lesions persisted and were successfully treated with 2 additional Xience V overlapping everolimus-eluting stents (Figure 3E). The patient’s angina resolved and he has remained symptom-free throughout 6 months of follow up.