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Multivessel percutaneous coronary intervention in midterm anastomotic failure of all grafts post CABG: An unpredictable enigma?

Coronary bypass graft failure can be divided into three temporal categories: Early (0–30 days), midterm (30 days to 1 year), or late (after 1 year). Early to midterm graft failure is still a significant problem in the clinical practice and often under reported. Here, we report a case of midterm failure of all grafts post CABG. A 56-year-old male presented to us with unstable angina and found to have triple vessel disease. He underwent CABG with left internal mammary artery (LIMA) to left anterior descending, venous grafts to diagonal and obtuse marginal. As ostial right coronary artery disease was moderate, it was not grafted. Three months later, he presented with acute coronary syndrome, acute heart failure, and moderate left ventricular (LV) dysfunction. Coronary and graft angiogram revealed critical anastomotic lesions of LIMA and both the venous grafts. Rapid progression of native vessel disease was also observed. He underwent successful multivessel percutaneous coronary intervention (PCI) with improvement in LV function. Midterm saphenous venous graft failure is mainly caused by neointimal hyperplasia leading to occlusive stenosis. Midterm failure of coronary artery bypass grafts is not a uniformly predictable response and has been the focus of extensive clinical research. Various mechanical strategies involving improvement of surgical techniques and various pharmacological strategies have been studied but did not address the problem adequately. PCI is the preferred strategy in these high-risk patients as it is less invasive and gives excellent results. Graft surveillance, early recognition of the problem and aggressive management has shown to improve the graft patency rates and decrease recurrent cardiovascular events in these patients.