title: Transient right internal thoracic arterial graft kink related to respiratory movements: documentation of its existence, relevance and proposed management.
abstract: In this case report, we provide the first detailed description of an intermittent mechanical kink of a right internal thoracic artery (ITA) graft to the left anterior descending coronary artery secondary to respiratory movements, and its assessment by pressure wire derived fractional flow reserve (FFR). The patient presented with recurrent unstable angina and documented anterior/anterolateral ischemia. Persistent symptoms were attributed to the ITA kink and stenting was planned on clinical grounds. However, the lesion proved not physiologically significant when FFR was assessed after intermittency related to respiratory movements was documented. Complex stenting was therefore avoided and medical therapy was prescribed for distal diagonal disease. We therefore propose that intermittency should be actively investigated when a kink is documented in a coronary bypass graft by conventional angiography (using dedicated angiographic evaluation in maximal inspiration and expiration). Furthermore, when this type of lesion is encountered, we suggest that it should be assessed physiologically using pressure wire derived FFR before potentially complex interventions are considered.
authors.affiliation: Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Pankert
authors.forename: Philippe L
authors.initials: PL
authors.lastname: L'Allier
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Tardif
mesh_terms: D000368:Aged; D000789:Angina, Unstable / Q000209:etiology / Q000503:physiopathology; D001794:Blood Pressure; D002317:Cardiovascular Agents / Q000627:therapeutic use; D017023:Coronary Angiography; D053805:Fractional Flow Reserve, Myocardial; D006083:Graft Occlusion, Vascular / Q000188:drug therapy / Q000209:etiology* / Q000503:physiopathology; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis; D008297:Male; D008323:Mammary Arteries / Q000503:physiopathology / Q000601:surgery*; D011237:Predictive Value of Tests; D012008:Recurrence; D012119:Respiration; D012307:Risk Factors; D013997:Time Factors
chemical_list: D002317:Cardiovascular Agents
keywords: angioplasty; coronary artery bypass; internal mammary artery graft; internal thoracic artery kink; myocardial fractional flow reserve; myocardial ischemia