Abstract-Text (inkl. Referenzen und Bildunterschriften)

A 72-year-old man presented at the emergency department with acute coronary syndrome. Prior to the admittance, a treadmill testing yielded positive evidence for myocardial ischemia. The patient is known to have 3 vessel-coronary artery disease, which was treated in 2016 by coronary artery bypass graft surgery. To rule out a progression of the coronary artery disease a coronary angiography is conducted. Because of the history of CABG a femoral access was favoured. The left anterior descending artery had a proximal occlusion, with multiple small thrombi adhering to the wall of the artery. The left circumflex artery revealed a proximal 50% stenosis whereas the first marginal branch showed a filiform stenosis with antegrade TIMI-I-flow and a washout via a suspected bypass graft. The right coronary artery revealed a proximal occlusion as a non-dominant vessel. Surprisingly the injection into the left internal mammary artery provided flow into the first marginal branch and not into the LAD as expected. Because of an extensive kinking of the right subclavian artery the RIMA could not be represented angiographically.In order to further demonstrate the second bypasses, a retrospective, ECG-gated Spiral-CT examination was performed. Here a continuous flow and course of the RIMA (!) to the LAD and the LIMA to first marginal branch was proven.
Typically, in most coronary artery bypass grafting (CABG)the LIMA is attached to the left anterior descending artery. In this case bilateral internal mammary artery grafting(BIMA) was carried out achieve total arterial left sidedmyocardial revascularization. Coronary CT angiography presented itself as an adequate tool with high diagnostic accuracy for the assessment of coronary bypass
grafts. It remains to be discussed if noninvasive bypass angiography with a cardio CT could be used as aprognostic tool in asymptomatic patients without proof of myocardial ischemia or could be a useful alternative in cases with unknown graft status.