The left internal mammary artery (LIMA) graft used in coronary artery bypass grafting (CABG) reliably revascularizes the left anterior descending artery (LAD) and has excellent long-term patency. Here, we report a rare case of ST-elevation myocardial infarction caused by acute occlusion of the LIMA in the late postoperative period. A 62-year-old man who underwent CABG for a myocardial infarction 15 years previously was transferred to our hospital for the recurrence of acute anterior myocardial infarction. Emergent cardiac catheterization revealed complete occlusion from the mid-portion of the LIMA to the LAD. We successfully treated this patient with primary stent implantation to the culprit LIMA lesion using intravascular ultrasound guidance.