M.S.

We have a 53 years old male with background Diabetes Mellitus and Hypertension. He had underwent bypass surgery previously in 2013 with 3 saphenous venous grafts. He complained of chest pain for 4 days, in which he was referred to us from another centre for urgent graft study. 

Baseline Echocardiography showed LVEF of 33%. Otherwise clinically he was unremarkable with clear lungs on auscultation.Coronary angiogram of native coronary arteries showed severe 3-vessel coronary artery disease with complete occlusions in all vessels. On top of that distal vessels of LAD and OM showed diffuse disease.

Grafts were checked. One stump was found. Saphenous venous graft to LAD had severe disease in the proximal part. Saphenous venous graft has tight stenosis in the proximal part with long thrombus arising from plaque.In view of absence of support from native vessels, patient was counselled on high risk PCI. 

Sheathless IABP inserted via left femoral access. Subsequently JR 3.5 guiding catheter used.The SVG-OM graft was engaged first. It was gently pre-dilated with 2.5 x 15 mm semi-compliant balloon. This allowed the 4.0 mm x 190 cm SpiderFX device to pass and placed in distal graft. Intermittent shot showed the thrombus not being displaced. Subsequently the lesion was stented with Resolute Oyx 3.0 x 22 mm. Thrombus aspiration was performed with Export Advance aspiration catheter. Stent post dilated at ostium with 3.5 x 12 mm NC balloon. Removal of embolic protection device revealed large amount of thrombus and complete resolution of graft patency.Similar technique was used for SVG-LAD graft. Gentle pre-dilation was done with same balloon with subsequent deployment of same SpiderFX 4.0 mm device. Despite graft lumen being larger, this was accepted as the graft being intervened has minimal/no thrombus burden. Stenting was done with Resolute Onyx 4.0 x 15 mm balloon. Good results was obtained with no post-dilation performed. No thrombus was extracted from SpiderFX device.IABP was removed post procedure with both groins closed with Angioseal closure device.

This case illustrates the strength and proper use of embolic protection device. Despite recent downgrade in level of evidence for use in graft intervention, embolic protection device may become necessary in certain high thrombus burden grafts. Careful selection of patients with proficiency in use can guarantee success of procedure without complications.