CASE 33 Dissection of Both a Left Internal Mammary Graft and the Subclavian Artery
Cardiac catheterization
An elective diagnostic coronary angiogram found no significant obstructive disease in the right coronary artery. The left internal mammary artery graft was widely patent but there was severe narrowing within the stent placed 8 years earlier (Figure 33-1 and Video 33-1). In addition, there was obstructive narrowing of the left circumflex artery proximal to an old stent (Figure 33-2) and chronic occlusion of the proximal left anterior descending artery. Based on these findings, the operator planned to treat the circumflex lesion and then the in-stent restenosis in the native left anterior descending artery, to be accessed via the left internal mammary artery graft using bivalirudin as the procedural anticoagulant. The circumflex lesion responded well to balloon dilatation followed by placement of a 3.5 mm diameter by 23 mm long everolimus-eluting stent (Figure 33-3).
