A 54-year-old hard-working male journalist underwent 4-vessel aortocoronary bypass grafting in January 2002 after 2 myocardial infarctions. The first diagonal and the second obtuse marginal branches were each supplied by a saphenous vein graft, the first obtuse marginal branch was supplied by a radial artery graft, and the distal left anterior descending artery was perfused by a left internal mammary artery graft.

Three years after bypass graft surgery, the patient was referred to our site because angina recurred. His chief symptom was burning retrosternal chest pain, similar to the symptoms he experienced before bypass surgery; however, dyspnea was absent this time. His cardiovascular risk factors were arterial hypertension, type 2 diabetes mellitus, and a history of smoking. Noninvasive examination by 64-slice computed tomography (CT) and invasive angiography were performed because the patient's symptoms indicated possible bypass graft disease. The 64-slice CT angiography scan accurately allowed significant bypass graft disease to be ruled out, and invasive angiography confirmed these findings (Figure 1). Results of gastrointestinal endoscopy showed that grade III reflux esophagitis was the cause of the patient's symptoms.

Figure 2 shows a 64-slice CT angiography scan of a 73-year-old man who underwent 5-vessel bypass grafting 15 years earlier. His cardiovascular risk factors included arterial hypertension, hypercholesterolemia, and a history of smoking. He described symptoms of unstable angina pectoris and an escalation of his chest pain from stress-dependent to pain at rest over the last months.

Figure 1. A 54-year-old patient with retrosternal chest pain 3 years after 4-vessel bypass grafting underwent computed tomography angiography. Three-dimensional reconstructions (A and B) demonstrate 4 patent bypass grafts. Invasive angiography confirmed patent saphenous vein grafts to the first diagonal branch (C) and second obtuse marginal branch (D), as well as a patent radial artery graft to the first obtuse marginal branch (E) and a patent left internal mammary artery graft to the left anterior descending artery (F). (Reprinted with permission from Meyer TS, Martinoff S, Hadamitzky M, et al. Improved noninvasive assessment of coronary artery bypass grafts with 64-slice computed tomographic angiography in an unselected patient population. J Am Coll Cardiol. 2007;49[9]:946-950.)

Figure 2. A 73-year-old male patient with stable angina underwent computed tomography angiography (CTA) 15 years after 5-vessel bypass grafting. The 3-dimensional reconstruction (A) and invasive angiography (B-D) demonstrate an occluded saphenous vein graft to the diagonal branch at the aortic anastomosis site (A), a severely stenosed saphenous vein graft to the right coronary artery (B), a moderately stenosed saphenous vein jump graft to the first and second obtuse marginal branches (C), and a left internal mammary graft to the left anterior descending artery with a significant stenosis at the distal anastomosis site (D). Invasive angiography confirmed the CTA findings. (Reprinted with permission from Meyer TS, Martinoff S, Hadamitzky M, et al. Improved noninvasive assessment of coronary artery bypass grafts with 64-slice computed tomographic angiography in an unselected patient population. J Am Coll Cardiol. 2007;49[9]:946-950.)