an abnormality in the formation and integrity of elastic fibers in marfan syndrome causes weakening of the aorta , leading to dilatation and dissection . aortic root dilation is the most common cause of morbidity and mortality . if the aortic root dilates to 5 cm or more , then prophylactic surgery should be considered . there are three techniques in the bentall procedure including the classic technique , the button technique , and the cabrol procedure that are commonly used techniques for re - implantation of coronary arteries after repair of the ascending aorta.1 - 5 ) the cabrol technique includes replacement of the ascending aorta and aortic valve using a composite graft . then , a second dacron tube graft ( approximately 60 - 80 mm in length ) is used with one end fashioned in an end - to - side anastomosis with the ascending aortic graft , and the other as an end - to - end anastomosis with the native coronary ostia.6 ) though there have been several reports about percutaneous intervention of the chronic stenotic cabrol graft - coronary ostial anastomotic lesions,7 - 10 ) the case with acute graft thrombosis has not been reported . koh et al.11 ) reported 2 cases ( 25% ) of mortality when they performed a modified bentall operation due to left ventricular failure , arrhythmia and bleeding . here we report the first case of acute st segment elevation myocardial infarction caused by thrombosis during the twisting of a cabrol graft - right coronary anastomotic lesion 12 days after surgery . the patient was successfully treated with a primary percutaneous coronary intervention ( pci ) and discharged without complications . a 52-year old woman with marfan syndrome was admitted to the emergency department complaining of acute resting chest pain for one hour . three years prior she had undergone a total aortic arch replacement due to aortic arch dissection with descending thoracic aortic aneurysm . the patient also had a cabrol - type bentall operation in another hospital using a st . her electrocardiogram on arrival showed st - elevation in the inferior leads and st - depression in the i , avl , v3 - 6 . initial cardiac biomarkers showed a slightly elevated troponin t of 0.15 ng / ml but were otherwise unremarkable . though she took warfarin , the prothrombin time expressed as a normalized international ratio was 1.6 on admission . because her initial blood pressure was too low to measure , she was started on hydration with normal saline , inotropic support and transferred immediately to the catheter laboratory for primary pci . during coronary angiography , a 6 fr ebu guiding catheter ( medtronic , minneapolis , mn , usa ) was easily inserted into the left cabrol composite graft ostium . the left limb of the graft was found to be fully patent with normal flow { thrombolysis in myocardial infarction ( timi ) grade 3 } down to the left coronary artery . however , the right limb of the cabrol composite graft ostium was not found initially . aortic root angiography did not show the right limb of the cabrol graft ostium . with eager , we could insert a 7 fr multipurpose guiding catheter ( cordis , johnson and johnson , cordis , miami lakes , fl , usa ) into the right limb of the cabrol composite graft ostium . the right limb of the graft was totally obstructed ( timi grade 0 ) by heavy thrombi at the cabrol graft to the right coronary artery ( rca ) anastomosis site ( fig . initially , we tried to aspirate with an intracoronary suction catheter using an export aspiration catheter ( medtronic , minneapolis , mn , usa ) , but it was not passed due to tortuosity . after ballooning of the anastomosis site , the whole right coronary arterial system was visible angiographically . the anastomosis site between the cabrol graft and the rca pre - dilatation was performed using a 4.020 mm sprinter semi - compliant balloon ( medtronic , minneapolis , mn , usa ) and then a 5.020 mm liberte ( boston scientific , natick , ma , usa ) bare metal stent was deployed at the cabrol graft to the rca anastomosis site . the entire lesion including the anastomosis site was postdilated using a 5.08 mm quantum non - compliant balloon ( boston scientific , natick , ma , usa ) . after post - dilation , the ivus study revealed optimal stent deployment and lesion coverage ( fig . the coronary ct angiography showed severe angulation and tortuosity between the rca and the right limb of the cabrol graft ( fig . although the cabrol technique is extremely useful in cases of re - operation in which mobilization of the aortic root is made very difficult by tight adhesion,1 ) early 30-day mortality rates using this procedure have been reported to be as high as 20% . recent reports showed that early 30-day mortality rates using this procedure had decreased to 4% to 11% , but overall mortality was 12% to 22%.12)13 ) in contrast , a button technique showed 1.9% early mortality.14 ) so , the cabrol technique should be used rarely and only when a button technique is not feasible.4 ) although coronary stenosis after a bentall procedure is uncommon , occurring in less than 2% of patients , the main concern with the cabrol technique is maintaining the patency of the dacron interposition grafts.7 - 10)13)15 - 18 ) kim13 ) reported that 4 cases ( 44.4% ) of dacron interposition graft stenosis were observed in patients undergoing a cabrol procedure . these lesions have usually been managed surgically15 - 17 ) although some reported cases have been managed by pci.7 - 10 ) one of the important causes of early in - hospital mortality is acute thrombosis of the coronary grafts . this can be one of the causes of early onset sudden death.1)4 ) however , there have been no reported cases that have been managed by pci in acute coronary graft thrombosis . however , our case suggests the possibility of thrombus formation . because the right limb of the cabrol graft was too long , it may have kinked , produced a size discrepancy and slow flow , and formed a thrombus in the anastomosis site . therefore , meticulous management of a cabrol graft anastomosis site , and sufficient early postoperative anticoagulation is warranted . this is the first report of acute st - elevation myocardial infarction that developed due to thrombi in a kinked cabrol coronary graft twelve days after operation . because the patient transferred to a surgical hospital , we only did follow up with her by telephone . she has had no major cardiac event over one year of follow up . for patients who undergo a cabrol procedure , the main concern is maintaining the patency of the dacron interposition grafts .
the cabrol procedure is one of several techniques used for re - implantation of a coronary artery . 
 after replacement of the ascending aorta and aortic valve using a composite graft , second dacron tube grafts are used for anastomosis between the ascending aortic graft and the coronary arteries . 
 ostial stenosis is one of the complications associated with the cabrol operation . 
 however , there have been no reported cases of acute thrombosis of a cabrol graft . 
 here we report a case with acute st elevation myocardial infarction due to thrombotic total occlusion of a right cabrol graft - to - right coronary artery ( rca ) twelve days after surgery in a patient with marfan syndrome . 
 he was successfully treated with primary percutaneous coronary intervention ( pci ) .