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Extensive Dissection of the Left Internal Mammary Artery Graft and Emergency Bail Out

Jien Sze Ho, Wei Chieh Tan Jack

Background: Left internal mammary artery (LIMA) bypass graft to the left anterior descending artery (LAD) have better long-term survival when compared with the use of a venous conduit to the LAD. It is a very important lifeline for coronary artery bypass patients and dissection of the LIMA is often disastrous.

This case illustrates an extensive dissection of the LIMA, involving the subclavian artery and aorta after bypass graft angiography. This was followed by an emergency bail out procedure.

Case Report: A 60-year-old gentleman presented with unstable angina underwent a routine diagnostic angiogram. Shortly after automated contrast injection of the left internal mammary artery (LIMA) graft, a column of contrast was found trapped in the subclavian artery. A review of the LIMA angiography revealed a spiral dissection extending distally from the ostial to distal LIMA, and also proximally from LIMA to subclavian artery down the aortic arch. Patient immediately deteriorated with hypotension and experienced chest pain. Emergency stenting of the left subclavian artery was performed. However, LIMA remained occluded. Cardiothoracic surgeons were consulted but acute redo coronary artery bypass was considered to be extremely high risk. In an attempt to bail-out the acutely occluded LIMA, we proceed with percutaneous coronary intervention of the native left anterior descending (LAD) artery chronic total occlusion. Fortunately, this was successful and stents were implanted from left main artery to distal LAD..