Kitazono Kazunari, Tanoue Kanyo, Ueno Masahiro, Ohishi Mitsuru
Tenyokai Chuo Hospital, 6-7 Izumi-cho, Kagoshima 892-0822, Japan.
Tanegashima Medical Center, 7463 Nishinoomote, Kagoshima 891-3198, Japan.
Eur Heart J Case Rep. 2021 Jan 4;5(2):ytaa543. doi: 10.1093/ehjcr/ytaa543. eCollection 2021 Feb.
Primary percutaneous coronary intervention (PCI) for acute coronary syndrome has significantly contributed to improvements in overall outcomes. However, clinical challenges exist when performing urgent PCI for patients with a history of coronary artery bypass grafting (CABG).
An 83-year-old man with a history of CABG presented with an inferior ST-elevation myocardial infarction (STEMI). Emergent coronary angiography showed an occlusion of the right coronary artery that had been previously grafted with the right gastroepiploic artery. Primary PCI for the native coronary artery was performed on the assumption that the bypass graft had been occluded. We were unable to attain angiographic antegrade flow after balloon angioplasty, and intravascular ultrasound revealed a ruptured plaque with a thrombus proximally and a patent bypass graft with complete recanalization distally. These findings suggested that the plaque rupture with resultant thrombus formation proximal to the anastomosis eventually overlay the patent bypass graft. Subsequent stent implantation covering only the culprit site with a residual stenosis proximal to the anastomosis was performed, resulting in good patency of both the native coronary artery and bypass graft for more than 3 years.
This is the first documented case of a patient with STEMI due to proximal native coronary artery occlusion with a thrombus overlying a patent bypass graft. Intravascular ultrasound was helpful to recognize the distal patency and guide optimal stent implantation. This case illustrates the complexity of treating a patient with a history of CABG and the importance of a multifaceted approach in such an urgent situation.
急性冠状动脉综合征的直接经皮冠状动脉介入治疗（PCI）对改善总体预后有显著贡献。然而，对于有冠状动脉旁路移植术（CABG）病史的患者进行紧急PCI时存在临床挑战。
一名有CABG病史的83岁男性出现下壁ST段抬高型心肌梗死（STEMI）。急诊冠状动脉造影显示右冠状动脉闭塞，该血管先前已用右胃网膜动脉进行了旁路移植。在假定旁路移植血管已闭塞的情况下，对自身冠状动脉进行了直接PCI。球囊血管成形术后未能获得血管造影的正向血流，血管内超声显示近端有破裂斑块伴血栓形成，远端旁路移植血管通畅且完全再通。这些发现提示吻合口近端的斑块破裂并形成血栓最终覆盖了通畅的旁路移植血管。随后仅在罪犯部位植入支架，吻合口近端有残余狭窄，术后自身冠状动脉和旁路移植血管均保持良好通畅超过3年。
这是首例记录在案的因自身冠状动脉近端闭塞伴血栓覆盖通畅旁路移植血管而导致STEMI的患者。血管内超声有助于识别远端通畅情况并指导最佳支架植入。该病例说明了治疗有CABG病史患者的复杂性以及在这种紧急情况下采取多方面方法的重要性。
