PCI Strategy in a Patient with Multi Venous Grafts Failure after Second CABG and Multi-Vessel CTOs: a Case Report

Long-term patency of saphenous vein grafts remains low. Recurrent ischemia after late graft failure can be treated by re-operation or percutaneous coronary intervention (PCI). The intervention can be performed in the native artery or the bridging vein graft. We report a case of 62-year-old patient, who presented with a recurrent ischemic heart disease despite many revascularization attempts. In 1991, CABG with three saphenous vein grafts (SVGs) was performed after STEMI of the inferior wall. Due to unstable angina and occlusion of all SVGs, a second CABG with two SVGs was performed in 2005. In 2009, SVG anastomosis to OM2 was stented with DES due to NSTEMI. Later he experienced some episodes of exertional angina pectoris. Coronary angiograms revealed occlusions of RCA 2 Miha Mrak and Matjaž Bunc and OM2 SVGs. We decided for a two staged PCI with stenting of SVG to OM2 and of CTO in the native RCA. SVG was again occluded 3 years after stenting. We successfully performed PCI of LCX CTO. Decision about revascularization must consider possible risks of both surgical and percutaneous revascularization procedures. Guidelines prefer percutaneous treatment to re-operation, and PCI in the native artery to that in a vein graft. Our experience shows that management remains complex and that long-term results remain unsatisfying.