Case presentation

An otherwise healthy and active 65-year-old man, with a past history notable for coronary artery bypass surgery 14 years earlier consisting of a right internal mammary artery graft to the right coronary artery, presents for cardiac catheterization. Five years earlier, he presented with an acute inferolateral wall myocardial infarction and underwent bare-metal stent placement to the first obtuse marginal artery and to his first diagonal artery; a long occluded segment of the distal circumflex artery was noted and deemed not treatable percutaneously. He remained free of cardiac symptoms until 3 months prior to his presentation, when he developed effort angina. Anginal symptoms progressed and began limiting his ability to work in his yard or to engage in hunting and fishing. Medical therapy, consisting of metoprolol, long-acting nitrates, aspirin, clopidogrel, and simvastatin, failed to improve his symptoms and he was referred for cardiac catheterization. Physical examination and routine laboratory evaluations were unremarkable. His baseline electrocardiogram revealed a prior inferolateral infarction and an incomplete right bundle branch block.

Cardiac catheterization

Left ventricular systolic function was preserved, with an estimated ejection fraction of 60% and only mild inferior wall hypokinesis. A widely patent right internal mammary artery graft provided an excellent distal blood supply to a severely diseased right coronary artery (Figure 16-1). Stents placed in the diagonal and obtuse marginal arteries were widely patent and the previously-noted long occluded segment of the distal circumflex remained unchanged (Figure 16-2). A long, tubular stenosis of moderate severity was apparent in the midportion of the left anterior descending artery (Figure 16-3 and Videos 16-1, 16-2). Given the uncertainty of the stenosis severity, the operator measured fractional flow reserve using a pressure wire and intracoronary adenosine to achieve maximal hyperemia. With classic anginal symptoms despite maximal medical therapy and a fractional flow reserve measuring 0.78, the physician decided to revascularize the left anterior descending artery percutaneously. Following administration of intravenous heparin and eptifibatide, the operator directly stented the diseased segment using a 6 French left coronary guide catheter with a 3.0 mm diameter by 32 mm long sirolimus-eluting stent inflated to 12 atmospheres (Figure 16-4).

FIGURE 16-1 Patent right internal mammary artery graft to the severely diseased right coronary artery.

FIGURE 16-2 A large first obtuse marginal artery is free of disease; there is occlusion of a long segment of the distal circumflex artery (arrow).

FIGURE 16-3 Long, tubular stenosis in the midportion of the left anterior descending artery (arrow).

FIGURE 16-4 Position of the stent at the site of the lesion in the left anterior descending artery.

Immediately following stent deployment, the angiogram demonstrated free extravasation of contrast emanating from the midportion of the stented segment consistent with a coronary artery perforation (Figure 16-5