Variant angina pectoris may exist after coronary artery bypass grafting (CABG) and is usually accompanied by generalized vasospastic diseases such as Raynaud's phenomenon and migraine.[1] While the most common involvement is the right coronary artery (RCA), the left anterior descending artery (LAD) or co-involvement are less frequently observed.[2] Coronary artery vasospasm (CAV) developing after CABG may be manifested by refractory angina, malignant arrhythmias, ST segment elevation on electrocardiography (ECG), myocardial infarction, sudden hypotension, bradycardia and myocardial wall motion abnormalities, and sudden cardiac arrest.

The relationship between coronary artery disease (CAD) and CAV is frequently investigated in the literature. However, there are limited case reports related to CAV after CABG. Herein, we present that successful treatment of CAV after CABG operation in a 48-year-old, active smoker, female patient with cardiological follow-up due to stable angina preoperatively.

Firstly, RCA imaging was performed on coronary angiography. The RCA, which was completely normal preoperatively (Figure 2a), suffered from a totally spasm from the proximal segment to distal segment (Figure 2b). The vessel was reached using a guidewire, and intracoronary nitroglycerin was applied (Figure 2c). However, percutaneous coronary angioplasty (PTCA) was applied to the RCA, as the vasospasm did not regress and hemodynamic instability persisted (Figure 3a). The patient was taken to the intra-aortic balloon pump (IABP) (Datascope CS300®, Getinge, Sweden) support instead of increasing the positive inotropic support due to possible vasospasm effects. The RCA was clear on control angiography, and the patient provided hemodynamic stability rapidly after IABP support. Subsequently, other coronary imaging studies were performed, and the graft anastomosis was well-perfused and clear (Figure 3b). The IABP support was continued, until the third postoperative day. Meanwhile, intravenous nitroglycerin treatment (0.25-1 ?g/kg/min; Perlinganit®, ADEKA Pharmaceuticals, Istanbul, Turkey) with a calcium channel blocker (5-15 mg/h; Diltizem®, Gensenta Pharmaceuticals, Istanbul, Turkey) was applied. On daily echocardiographic evaluation, right ventricular myocardial wall motion abnormality was unable to be seen. The patient was taken to the ward. Nitroglycerin (50 mg/day; Monoket Long®, ADEKA Pharmaceuticals, Istanbul, Turkey) and diltiazem (90 mg/day; Diltizem SR®, Gensenta Pharmaceuticals, Istanbul, Turkey) treatment continued orally. On Day 6 after the operation, the patient was discharged with recommendations.

Figure 1: ST segment elevation and third-degree atrioventricular block on electrocardiography.

Figure 2: (a) Angiographic imaging of right coronary artery before the operation. (b) Angiographic imaging of right coronary artery suffering from vasospasm after operation. (c) Angiographic imaging of ostial vasospasm continuing after nitroglycerin treatment.

Figure 3: (a) Angiographic imaging of right coronary artery after percutaneous coronary intervention. (b) Angiographic imaging of left internal mammary artery-left anterior descending artery perfusion after surgery.

The importance of diagnosing early CAV, which can cause serious, life-threatening hypotension immediately after CABG, has been well-documented in the literature.[4] In our case, emergency coronary angiography was performed to the patient to confirm our suspicion of CAV, to rule out graft failure or possible new-onset stenosis, and to allow intracoronary administration of vasodilators agents, after the patient became hemodynamically suitable for transportation. Calcium channel blockers or nitroglycerin administered intracoronary have been shown to be effective in most cases.[6] However, as in this case report, while nitroglycerin infusion treatment continued, PTCA was applied as the next treatment step to ensure hemodynamic stability in the patient who developed CAV and the patient was, then, successfully followed with long-term nitrate and calcium channel blocker therapy.

In conclusion, in this case report, we emphasize that the hemodynamic instability developed after a routine and successful operation in the early period following CABG should be managed correctly and that CAV should not be overlooked. In the course of CAV extending to variant angina, myocardial infarction, malignant arrhythmia and even sudden cardiac arrest, we believe that early diagnosis and proper treatment are life-saving for these patients.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

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