A 72 years old man was admitted in CCU for unstable angina (IIB Braunwald UA classification). In 1995 he underwent CABG with a  single venous graft implantation from the right coronary ostium (see fig 1)  to the mid portion of LAD. In the surgical report the surgeon described a severe and diffuse heavy calcified aortic root (“porcelain” like).

In 1998 the patient underwent to bi iliaco-femoral grafting for high degree multiple and bilateral stenosis of iliac and femoral vessels.

Angiography, by right radial approach, showed that the  RCA was totally occluded in the mid portion;  LAD was diffusely diseased and occluded in mid portion; LCx showed just a sub critical stenosis. The vein graft (starting from right coronary sinus –the only no calcified site-) had an unusual loop shape (“up and down”)  (fig 1) and it was slightly  diseased with severe stenosis (> 80%) at the level of the anastomosis (in the mid LAD portion). It showed second degree of collateral vessels from septal branch to distal portion of the RCA.

Left ventricular  function was depressed (E.F.38%) with inferobasal akinesia.

We performed, by using Mammary guiding catheter (Medtronic) and Extrasport guide wire, direct stent implantation at the LAD anastomosis (Guidant Penta Ô 3.0/18 mm at 17 atmospheres for 20” ) and balloon overdilatation  ( NC VIVAÔ 3.25mm –Scimed Boston Scientific- at 20 atmospheres). Good result (Fig 2 and 3).