TOUGH Syndrome: A Report of an Early Immediate Postoperative Cause of Aortocoronary Graft Occlusion.

Aortocoronary artery bypass grafts are time tested to be effective definitive therapy of symptomatic coronary artery disease since their inception in the 1960s. Over the years, multiple factors have affected the long-term outcome and patency rates of vein grafts. These can be divided into acute, subacute, and delayed categories. The most common causes, respectively, are thrombosis, intimal hyperplasia, and accelerated atherosclerosis. Numerous studies have analyzed postoperative angiographic images to evaluate these phenomena, and medical therapies have been instituted to prevent occlusion of these grafts. Besides these pathologic mechanisms, a surgeon and the surgeon's team must be aware of potential early reversible causes of coronary occlusion that are most often mechanical in nature. Graft kinking and external compression are known adverse events that may require early intervention to correct the underlying cause of graft occlusion. Here we present a case of graft occlusion by what we refer to as TOUGH syndrome: Thoracostomy tube Occluding Underlying coronary Graft causing Harm.