Deliberate radial artery graft occlusion following left circumflex artery stenting

A 64-year-old man, with a history of coronary artery bypass graft surgery (CABG; left internal mammary artery to left anterior descending artery, radial artery [RA] to obtuse marginal branch and Y-shaped composite saphenous vein graft to right posterior descending and posterior left ventricular arteries) 16 months prior, experienced exercise-induced angina with evidence of reversible ischemia over the basal and apical lateral left ventricular wall demonstrated on exercise stress nuclear myocardial perfusion imaging.Conventioanl angiography showed that all grafts were patent except from the RA which showed a highgrade stenosis at the distal anastomosis (Figure 1A).Furthermore, there has been a progression of atherosclerotic disease of the native left circumflex (LCx) artery since its angiographic diagnosis before CABG (Figure 1B-C).We successfully performed intravascular ultrasound-guided percutaneous coronary intervention (PCI) of the native LCx artery using two overlapping drug-eluting stents in the direction of the large-sized obtuse marginal branch while the stent-jailed distal LCx artery was treated with a paclitaxel drugcoated balloon (Figure 1D; Supplementary material, Figure S1, Videos S1 and S2).After