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This case report describes functional occlusion of a left internal mammary artery (LIMA) graft caused by flow competition with a centrally anastomosed saphenous vein graft (SVG). Transit-time flow measurements showed contrasting mean graft flow, pulsatility index, and especially high backward flow. Temporary SVG clamping changed parameters, yet the plan was not altered; follow-up confirmed LIMA string-sign occlusion and a patent SVG, prompting left main stent implantation.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/should-we-ligate-coronary-conduits-when-flow-measurements-indicate-competitive-flow-a-case-report/455779/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/should-we-ligate-coronary-conduits-when-flow-measurements-indicate-competitive-flow-a-case-report/455779.png","ImageObject",300,407,{"name":92,"@type":93},"Jake","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",13,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What is competitive flow in CABG and why can it matter?","Question",{"text":113,"@type":114},"Competitive flow occurs when graft flow is impaired by higher competing flow from the native circulation or another graft. It may lead to functional graft occlusion and later graft failure.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"How did the transit-time flow measurements suggest competitive flow in this case?",{"text":118,"@type":114},"The LIMA had a higher pulsatility index and notable backward flow, leading to suspicion of competitive flow. Temporary SVG clamping reduced backward flow in the LIMA measurements.",{"name":120,"@type":111,"acceptedAnswer":121},"What was the clinical outcome after the initial decision not to change the revascularization plan?",{"text":122,"@type":114},"The patient was initially discharged uneventfully, but at 6 months he developed symptoms and poor ejection fraction. 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Journal of Cardiothoracic Surgery (2026) 21:12  \n[https://doi.org/10.1186/s13019-025-03529-0](https://doi.org/10.1186/s13019-025-03529-0)  \nJournal of Cardiothoracic Surgery  \nCASE REPORT Open Access  \nShould we ligate coronary conduits when flow  measurements indicate competitive flow? a case report  \nKonstantinos Papakonstantinou 1*, Panagiotis Lerios 1, Mihalis Argiriou 1, Vasilios Patris 1, Ilias Gissis 1, John Kokotsakis 1, Panagiotis Dedeilias 1 and Periklis Tomos2  \nAbstract  \nBackground Competitive flow (CF) in coronary artery bypass grafting (CABG) occurs when graft flow is impaired due to higher competing flow from either the native circulation or another graft and may result in functional  \ngraft occlusion. We report a case of functional graft occlusion of a left internal mammary artery (LIMA) due to flow competition with a saphenous vein graft (SVG) and discuss the rationale of ligating the graft responsible for the CF. Case presentation The case refers to a 56-year-old man with an isolated subtotal ostial left anterior descending (LAD) lesion who underwent conventional double on-pump CABG with an in situ (LIMA) to the LAD and a centrally anastomosed SVG to the Diagonal branch (D1) . Concerning the initial Transit-time flow measurements (TTFM), the SVG had a mean graft flow (MGF) of 49 ml/min, a Pulsatility index (PI) of 1 and a Diastolic flow (DF) of 66% . The LIMA graft had an MGF of 31 ml/minute, a PI of 3 . 8, a DF of 80%, but a Backward flow (BF) of 8% . As the LIMA BF was quite high, we suspected competitive flow of the graft and thus decided to transiently apply a bulldog clamp to the SVG, to check if the LIMATTFM would change. Indeed, MGF was 44 ml/minute, the PI was 2. 3, DF was 60%, and BF was 0. 9% . Despite these results, the operating surgeon did not alter the revascularization plan and the operation was finished. The patient was discharged uneventfully. However, in a 6-month follow-up, the patient was symptomatic and with poor ejection fraction, and the diagnostic work-up revealed the functional occlusion of the LIMA graft with a string sign, and a patent SVG. After Heart Team consultation and patient update, he underwent left main stent implantation. Conclusions There should be a great degree of suspicion for CF with high BF values, even when the rest ofthe parameters measured during TTFM are normal or marginal. Also, the location of the LAD stenosis proximal to the D1 is a risk factor for CF when both arteries are grafted. Changing the revascularization plan based on TTFM is warranted for optimal outcomes.  \nKeywords Transit-time flow measurement, Competitive flow, Case report  \n*Correspondence:  \nKonstantinos Papakonstantinou  \n[kostispap@windowslive.com](kostispap@windowslive.com)  \n1Department of Cardiothoracic and Vascular Surgery, Evangelismos General Hospital of Athens, Athens, Greece  \n2“Attikon” University Hospital of Athens, Athens, Greece  \n© The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creativecommons.org/l](http://creativecommons.org/l)icenses/by/4.0/.  \nPapakonstantinou et al. Journal of Cardiothoracic Surgery (2026) 21:12 Page 2 of 6  \nBackground  \nBackward flow (BF) in coronary artery byp","cbCailbCj5Eiq763","https://ap.wps.com/l/cbCailbCj5Eiq763","pdf",1304785,"English","# Background\n# Case presentation\n## Pre-operative findings\n## Intraoperative TTFM and management decision\n# Follow-up and outcomes\n# Discussion\n# Conclusions","[{\"question\":\"What is competitive flow in CABG and why can it matter?\",\"answer\":\"Competitive flow occurs when graft flow is impaired by higher competing flow from the native circulation or another graft. It may lead to functional graft occlusion and later graft failure.\"},{\"question\":\"How did the transit-time flow measurements suggest competitive flow in this case?\",\"answer\":\"The LIMA had a higher pulsatility index and notable backward flow, leading to suspicion of competitive flow. Temporary SVG clamping reduced backward flow in the LIMA measurements.\"},{\"question\":\"What was the clinical outcome after the initial decision not to change the revascularization plan?\",\"answer\":\"The patient was initially discharged uneventfully, but at 6 months he developed symptoms and poor ejection fraction. Work-up showed functional occlusion of the LIMA graft with a string sign while the SVG remained patent, leading to left main stent implantation.\"}]","Should we ligate coronary conduits when flow measurements indicate competitive flow - a case report | PDF",1790744308,15]