APCU25CR19 Venous graft occlusion detected on ECHO: a case report

Introduction This case report details a rare instance where a saphenous vein graft (SVG) to the right posterior descending artery (RPDA) was clearly visualized via echocardiography, a technique not typically used for this purpose. The patient, a 78-year-old male with a history of coronary artery bypass grafting (CABG), presented with angina and required urgent cardiac evaluation. The case highlights the unexpected diagnostic utility of echocardiography in identifying coronary graft issues, particularly when conventional imaging methods are contraindicated.Case Presentation A 78-year-old male with a history of triple vessel disease and CABG in 2005 presented with angina. Angiography revealed severe native vessel disease, including significant narrowing in the distal left main stem, proximal left anterior descending artery, distal diagonal 2, mid-left circumflex artery, and obtuse marginal 1. The graft study showed left internal mammary artery (LIMA) with distal thrombus and a functional SVG to the obtuse marginal branch. However, the SVG to the right coronary artery (RCA) was not visible. Due to concerns about contrast-induced nephropathy from the initial angiography, a planned CT coronary angiogram (CTCA) was not performed.Results During a detailed echocardiographic examination, the SVG to the RPDA was surprisingly and clearly visualized. This imaging revealed a significant flow blockage within the graft itself, confirming the cause of the patient‘s symptoms. This direct and clear echocardiographic identification of a distal graft is a very rare finding. The patient was treated with intravenous Tirofiban (Frinofiban) for the LIMA thrombus, in addition to his ongoing medications of Apixaban and Plavix.Discussion This case demonstrates the remarkable capability of echocardiography to provide a direct and timely diagnosis of distal coronary graft problems, which is uncommon for this imaging modality. While angiography is the gold standard for evaluating coronary arteries and grafts, this case shows that echocardiography can offer valuable, complementary diagnostic information, especially when other imaging methods are unavailable or risky. The ability to see the obstructed graft so clearly with a non-invasive tool provided critical information that corroborated the patient‘s symptoms.Conclusion This rare case underscores the potential of echocardiography to be a powerful diagnostic tool in complicated post-CABG patients. It can offer direct visualization of distal coronary grafts and their patency, providing essential diagnostic information that can enhance or even supplement traditional angiographic evaluations, particularly in situations where conventional imaging is not feasible. This observation is key for timely and effective patient management.