Case Report: Intravascular Ultrasound-guided Intervention for Anastomosis Stenosis of the Left Main Coronary Artery Post-Cabrol Technique

IntroductionSome cases of percutaneous coronary intervention (PCI) for the anastomotic site between the Cabrol-type conduit and the left main coronary artery (LMCA) have been reported. Nevertheless, the combination of PCI with a detailed description of lesion appearance using virtual histology-intravascular ultrasound (VH-IVUS) has never been reported. In this study, we present a case of acute myocardial infarction that was successfully treated with intravascular ultrasound (IVUS)-guided PCI for focal stenosis at the anastomotic site, and the plaque composition was studied in detail. Case PresentationA 35-year-old Korean male with Behcet's disease was diagnosed with acute myocardial infarction. He had previously undergone three cardiothoracic surgeries including two aortic replacements, followed by modified Bentall operation with a Cabrol-type aortocoronary anastomosis. Coronary angiogram (CAG) showed focal critical stenosis at the anastomosis site between the conduit and the LMCA, and VH-IVUS showed fibrotic plaque with mainly fibrous tissue but without a confluent necrotic core. PCI was performed using a drug-eluting stent (4.5 x 12 mm, Synergy(TM), Boston Scientific, Marlborough, MA, USA). Since a repeat CAG and IVUS post-surgery showed an under-expanded stent strut, post-dilation ballooning was additionally performed. Subsequently, the repeat IVUS revealed wellapposed and optimized deployment of the drug-eluting stent with full lesion coverage. Final CAG showed optimal angiographic results. After successful PCI, the patient's anginal symptoms improved dramatically, and he was successfully discharged from our hospital. ConclusionThis study presents an IVUS-guided PCI case for an anastomotic site between the conduit and the LMCA. It is the first to investigate the characteristics of this lesion through VH-IVUS, which demonstrated the presence of fibrous plaques at the anastomotic site. IVUS radiofrequency data allow for a detailed assessment of plaque composition and provide new insights into the histopathological nature of stenotic lesions at the anastomotic site, especially in patients with chronic inflammatory diseases like Behcet's disease.