Successful Rescue Intervention of Internal Mammary Artery Anastomotic Site Acute Graft Failure With Direct New Generation Covered Stenting

Acute, perioperative myocardial infarction (MI) from acute left internal mammary artery (LIMA) to left anterior descending (LAD) graft failure immediately following coronary artery bypass grafting (CABG) surgery is associated with significantly increased in-hospital mortality. The leading etiology of such acute graft failure is acute thrombosis, dissection, spasm, anastomosis failure or no-reflow phenomenon. Repeat bypass surgery carries incremental risk and may not be feasible in hemodynamically unstable patients. Traditional percutaneous coronary intervention (PCI), with or without stent placement is sometimes used in such cases; however, graft anatomy and lesion location increase procedural complexity and challenge technical feasibility. This is particularly true of the LIMA to LAD graft anastomosis, where PCI carries the risk of anastomotic site perforation or avulsion. Therefore, the best revascularization strategy for such a lesion involving the LIMA to LAD graft anastomosis in the immediate perioperative period remains unknown. We present a case of 75-year-old male who suffered an acute MI complicated by cardiogenic shock less than 24 h after two-vessel CABG. Selective angiography revealed acute LIMA to LAD anastomotic site closure, posing a risk for perforation if treated with traditional angioplasty or stenting. We successfully performed rescue PCI, by directly deploying a PK Papyrus covered stent (Biotronik, Berlin, Germany) across the anastomosis. Our case report describes the upfront (rather than a bail out) use of the new covered stent as a novel revascularization strategy to treat "perforation prone" LIMA to LAD anastomotic site acute graft failure.