Abstract
A 61-year-old man with history of coronary artery disease and coronary artery bypass graft presented with chest pain. A left heart catheterization showed a new kink in the body of his left internal mammary artery to left anterior descending artery graft. The kink improved with inspiration, which suggests re-assessment of similar cases should be done during deep inspiration. (Level of Difficulty: Intermediate.)
Key Words: acute coronary syndrome, coronary angiography, coronary artery bypass
Graphical abstract
A 61-year-old man with history of coronary artery disease and coronary artery bypass graft presented with chest pain. A left heart catheterization…
A 61-year-old man with a past medical history of coronary artery disease, prior quadruple coronary artery bypass grafting, and recent protected left main percutaneous coronary intervention presented to our emergency department with worsening chest discomfort and negative cardiac enzymes. Left heart catheterization showed a kink in the body of his left internal mammary artery (LIMA) to left anterior descending (LAD) graft that was not seen on an angiogram 6 weeks previously (Figure 1A, Video 1; Figure 1B, Video 2; previous and current angiogram, respectively). The kink in the LIMA did not respond to nitroglycerine or expiration (Video 3), but it improved with inspiration (Video 4). During fractional flow reserve, the wire straightened the kink (Figure 1C, Video 5). The fractional flow reserve was 0.93. Our suspicion is that the kink in the LIMA was not hemodynamically significant. Note that the saphenous vein graft to the diagonal also provided retrograde flow into the LAD. The patient was treated medically.
Figure 1.
Kink in LIMA to LAD Graft
(A) There was no kink in the left internal mammary artery (LIMA) to left anterior descending (LAD) graft previously. (B) Kinked area (white arrow) in the LIMA to LAD graft body. (C) The kinked area was straightened after placing the fractional flow pressure (FFR) pressure wire (blue arrowhead). See Videos 1, 2, 3, 4, and 5.
Online Video 1.
There was no kink in the LIMA to LAD graft body previously.
Online Video 2.
The kinked area in the LIMA to LAD graft body.
Online Video 3.
Intra-coronary nitroglycerin injection didn’t improve the kinked area.
Online Video 4.
The dynamic kinking area changes with breathing: improved with a deep breath and worsen with expiration.
Online Video 5.
The kinked area was straightened after placing the FFR pressure wire.
Kinking has been reported as a relatively uncommon etiology of LIMA graft failure 1, 2. This condition can present with recurrent angina symptoms and may require stent placement to the kinked site. Lack of response to intracoronary artery vasodilators can differentiate kinking from vessel spasm (2). However, dynamic graft kinking that significantly changes with respiration (like this case) has not been previously reported. When a kink within the LIMA is encountered, consideration should be given for re-assessment during deep inspiration.
Footnotes
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Appendix
For supplemental videos, please see the online version of this paper.
References
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