Natural Right Internal Mammary Artery to Left Circumflex Artery Bypass

Introduction

A 76-year-old man who had a history of diabetes mellitus, hypertension, and hyperlipidemia was referred to our hospital for surgical intervention of his coronary artery. He does not have any history of chest trauma previously. This patient also had a history of 2 previous percutaneous coronary artery interventions. In 2000, he underwent stent insertion to the right coronary artery (RCA) and the left circumflex artery (LCX) because of posterior acute myocardial infarction. In 2007, stent insertion was performed for a newly developed lesion of the RCA. Since that procedure, the patient was stable without chest pain. However, in 2013, he complained of severe chest pain on exertion and was emergently admitted to a local hospital. An ECG showed anterior wall ischemia. Acute coronary syndrome was suspected. Emergency coronary angiography was performed and revealed tight left main stenosis, 75% stenosis of the proximal left anterior descending artery, 99% stenosis of the proximal LCX, and 90% stenosis of the RCA. There was flow competition between the native LCX and the collateral artery (Figure 1, Movie I in the online-only Data Supplement). An internal mammary artery angiography was performed and …