In the current era, coronary artery bypass grafting (CABG) is being increasingly performed using total arterial revascularization or a hybrid procedure of stenting of non-LAD disease and minimal access left internal mammary artery (LIMA) to LAD grafts, in order to minimize the need for vein grafts. Still, we encounter saphenous vein graft (SVG) disease, and it might require PCI, which often presents with unique challenges. The current favored strategy is to attempt PCI of the native coronary, if feasible, especially in long degenerated SVG disease, as it has shown better short- and long-term outcome. PCI is preferred over repeat CABG for early recurrent symptoms after CABG in patent LIMA graft and amenable anatomy patients. Balloon predilatation is not recommended unless delivery of an EPD or stent is not possible. Distal protection should be considered the standard of care for percutaneous coronary intervention (PCI) in most patients with older vein grafts, as periprocedural myocardial infarction and no reflow are the Achilles heel of SVG PCI. Intragraft vasodilators should be used liberally, even before balloon angioplasty/stenting. Avoid postdilatation, and usage of undersized but a longer stent length to reduce plaque extrusion through stent struts is preferred. Consider thrombectomy in lesions with a heavy thrombus burden. Keep activated clotting time on the higher side than in conventional PCI. Prolonged dual antiplatelet therapy (DAPT) based on the DAPT score is recommended. With all the precautions and care, we still need a fair wind in our favor to sail through the vein grafts disease.

Hypertrophic cardiomyopathy is the most common heritable cardiomyopathy, manifesting as left ventricular hypertrophy. In this case, a 48-year-male patient presented with complaints of shortness of breath, uneasiness for 15 days, right lower limb pain, and one episode of fever for 2 days. He was initiated on antibiotics but gradually started developing hypotension and oliguria. After optimizing the medical therapy and as a life-saving measure, alcoholic septal ablation was done in this patient as a last resort. The patient was weaned off the ventilator after 72 h and discharged in a stable condition. He has continued follow-up for 8 months and is asymptomatic; the gradient has not recurred. The patient had both issues, and timely alcohol septal ablation helped save the patient by optimizing the hemodynamics. This is a rare situation of suicidal left ventricular induced by sepsis-induced vasodilation.