{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T04:46:51Z","timestamp":1785818811191,"version":"3.56.0"},"reference-count":23,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T00:00:00Z","timestamp":1785801600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The left internal mammary artery (LIMA) graft constitutes the optimal conduit for bypassing the left anterior descending (LAD) artery. Despite its overall excellent long-term patency, the LIMA graft may fail, most commonly because of competitive flow. In case of a failed LIMA graft, a percutaneous coronary intervention (PCI) of the LAD artery may be required to ensure better outcomes. However, persistent competitive flow from an anatomically patent but functionally occluded LIMA graft after a successful PCI of the LAD artery may adversely affect clinical outcomes by predisposing to in-stent restenosis (ISR) and stent thrombosis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case summary<\/jats:title>\n                    <jats:p>Herein, we present the case of a patient with unstable angina and a failed LIMA graft exhibiting the \u201cstring phenomenon\u201d because of competitive flow, necessitating a PCI of a high-grade stenosis in the LAD artery. Reverse LIMA graft flow, which is an indicator of severe competitive flow, was observed immediately after the PCI and during follow-up angiography, which also revealed an ISR of the LAD artery. Stent failure was attributed to the persisting competitive flow and was managed with drug-coated balloon angioplasty. In order to nullify any future deleterious effects of the competitive flow, we applied the \u201ccondom technique\u201d to sacrifice the dysfunctional LIMA graft. The first attempt to apply this technique was complicated by the dislodgment of the remnant balloon from the assembly and migration into the distal LAD artery; however, the second attempt was successful in achieving graft occlusion. The patient was discharged home in good condition and remained free of angina or any cardiovascular events at a 6-month follow-up. An angiogram performed seven months after the drug-coated balloon angioplasty for ISR and occlusion of the LIMA graft showed preserved patency of the LAD artery.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Deliberate occlusion of a dysfunctional LIMA graft following a PCI of the LAD artery may help reduce the risk of future episodes of stent failure. Choosing to sacrifice the graft using the \u201ccondom technique\u201d is feasible, safe, and effective, provided all steps of the technique are thoroughly reviewed and optimally performed.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fcvm.2026.1865177","type":"journal-article","created":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T04:27:39Z","timestamp":1785817659000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Case Report: Navigating the flow-dependent interaction between the left internal mammary artery graft and the left anterior descending artery: when deliberate graft occlusion comes into play"],"prefix":"10.3389","volume":"13","author":[{"given":"Andreas Y.","family":"Andreou","sequence":"first","affiliation":[{"name":"Department of Cardiology, Limassol General Hospital","place":["Limassol, Cyprus"]},{"name":"Department of Basic and Clinical Sciences, University of Nicosia Medical School","place":["Nicosia, Cyprus"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,4]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"150","DOI":"10.1016\/j.mayocp.2022.10.003","article-title":"Left internal mammary artery as an endocrine organ: insights into graft biology and long-term impact following coronary artery bypass grafting","volume":"98","author":"Shadrin","year":"2023","journal-title":"Mayo Clin Proc"},{"key":"B2","doi-asserted-by":"publisher","first-page":"512","DOI":"10.1093\/cvr\/cvq210","article-title":"Impact of competitive flow on wall shear stress in coronary surgery: computational fluid dynamics of a LIMA-LAD model","volume":"88","author":"Nordgaard","year":"2010","journal-title":"Cardiovasc Res"},{"key":"B3","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1161\/CIRCULATIONAHA.115.015549","article-title":"Frequency and predictors of internal mammary artery graft failure and subsequent clinical outcomes: insights from the project of ex-vivo vein graft engineering via transfection (PREVENT) IV trial","volume":"133","author":"Harskamp","year":"2016","journal-title":"Circulation"},{"key":"B4","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1007\/978-3-319-26515-5_25","article-title":"Competitive flow and coronary artery bypass grafts","volume-title":"Coronary Graft Failure: State of the Art","author":"Gaudino","year":"2016"},{"key":"B5","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1161\/CIRCULATIONAHA.115.020084","article-title":"Should coronary artery bypass grafting be performed in patients with moderate stenosis of the left anterior descending coronary artery?","volume":"133","author":"Sabik","year":"2016","journal-title":"Circulation"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1490","DOI":"10.1016\/s0003-4975(03)01022-1","article-title":"Does competitive flow reduce internal thoracic artery graft patency?","volume":"76","author":"Sabik","year":"2003","journal-title":"Ann Thorac Surg"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1049","DOI":"10.1016\/s0735-1097(98)00060-6","article-title":"Flow dynamics of angiographically no-flow patent internal mammary artery grafts","volume":"31","author":"Akasaka","year":"1998","journal-title":"J Am Coll Cardiol"},{"key":"B8","first-page":"346","article-title":"The string phenomenon: an important cause of internal mammary artery graft failure","volume":"27","author":"Villareal","year":"2000","journal-title":"Tex Heart Inst J"},{"key":"B9","doi-asserted-by":"publisher","first-page":"72","DOI":"10.1016\/j.xjtc.2021.11.014","article-title":"String sign recovery of the left internal mammary artery bypass graft","volume":"12","author":"Yazbeck","year":"2021","journal-title":"JTCVS Tech"},{"key":"B10","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1007\/978-3-319-26515-5_12","article-title":"Disease progression after CABG","volume-title":"Coronary Graft Failure: State of the Art","author":"Perek","year":"2016"},{"key":"B11","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1016\/j.amjcard.2024.06.015","article-title":"Impact of postprocedural graft flow on outcomes following chronic total occlusion intervention in postcoronary artery bypass graft patients: a detailed angiographic analysis","volume":"226","author":"Poletti","year":"2024","journal-title":"Am J Cardiol"},{"key":"B12","first-page":"C27","article-title":"The influence of shear stress on in-stent restenosis and thrombosis","volume":"4","author":"Wentzel","year":"2008","journal-title":"EuroIntervention"},{"key":"B13","doi-asserted-by":"publisher","first-page":"991","DOI":"10.1093\/eurheartj\/ehw095","article-title":"Diagnostic performance of cardiac imaging methods to diagnose ischaemia-causing coronary artery disease when directly compared with fractional flow reserve as a reference standard: a meta-analysis","volume":"38","author":"Danad","year":"2017","journal-title":"Eur Heart J"},{"key":"B14","doi-asserted-by":"publisher","first-page":"S47","DOI":"10.1016\/j.ihj.2015.07.029","article-title":"Rare case of proximal coronary plaque regression after distal arterial grafting","volume":"68","author":"Valooran","year":"2016","journal-title":"Indian Heart J"},{"key":"B15","doi-asserted-by":"publisher","first-page":"1065","DOI":"10.1161\/ATVBAHA.123.318239","article-title":"Hemodynamics and wall mechanics of vascular graft failure","volume":"44","author":"Szafron","year":"2024","journal-title":"Arterioscler Thromb Vasc Biol"},{"key":"B16","doi-asserted-by":"publisher","first-page":"e875","DOI":"10.4244\/EIJ-D-20-00487","article-title":"Management of myocardial revascularisation failure: an expert consensus document of the EAPCI","volume":"16","author":"Stefanini","year":"2020","journal-title":"EuroIntervention"},{"key":"B17","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1159\/000245634","article-title":"Haemodialysis-induced myocardial stunning in chronic kidney disease\u2014a new aspect of cardiovascular disease","volume":"29","author":"McIntyre","year":"2010","journal-title":"Blood Purif"},{"key":"B18","doi-asserted-by":"publisher","first-page":"1170","DOI":"10.1016\/j.jacc.2025.07.049","article-title":"Indications for use of drug-coated balloons in coronary intervention: academic research consortium position statement","volume":"86","author":"Fezzi","year":"2025","journal-title":"J Am Coll Cardiol"},{"key":"B19","doi-asserted-by":"publisher","first-page":"3320","DOI":"10.1093\/eurheartj\/ehv511","article-title":"Stent thrombosis and restenosis: what have we learned and where are we going? The Andreas Gr\u00fcntzig Lecture ESC 2014","volume":"36","author":"Byrne","year":"2015","journal-title":"Eur Heart J"},{"key":"B20","doi-asserted-by":"publisher","first-page":"E836","DOI":"10.25270\/jic\/22.00221","article-title":"Saphenous vein graft occlusion following native vessel chronic total occlusion percutaneous coronary intervention","volume":"34","author":"Kostantinis","year":"2022","journal-title":"J Invasive Cardiol"},{"key":"B21","doi-asserted-by":"publisher","first-page":"94","DOI":"10.1016\/j.jcin.2023.10.051","article-title":"An adaptable, cheap and easy-to-use interventional tool to obtain vascular sealing: the condom technique","volume":"17","author":"Agostoni","year":"2024","journal-title":"JACC Cardiovasc Interv"},{"key":"B22","doi-asserted-by":"publisher","first-page":"288","DOI":"10.33963\/v.phj.106943","article-title":"Deliberate radial artery graft occlusion following left circumflex artery stenting","volume":"84","author":"Andreou","year":"2026","journal-title":"Kardiol Pol"},{"key":"B23","doi-asserted-by":"publisher","first-page":"102577","DOI":"10.1016\/j.jaccas.2024.102577","article-title":"Mechanical barrier for prevention of dislodged stent embolization in saphenous vein graft","volume":"29","author":"Bouratzis","year":"2024","journal-title":"JACC Case Rep"}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2026.1865177\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T04:27:42Z","timestamp":1785817662000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2026.1865177\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,4]]},"references-count":23,"alternative-id":["10.3389\/fcvm.2026.1865177"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2026.1865177","relation":{},"ISSN":["2297-055X"],"issn-type":[{"value":"2297-055X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,4]]},"article-number":"1865177"}}