Treatment of a Degenerated Vein Graft

This older patient had bypass surgery 15 years ago for severe angina and coronary disease. He also has atrial fibrillation and is maintained on Coumadin anticoagulation. There is also moderate left ventricular dysfunction.

He presented to the ER with chest pain and a Non-ST-elevation MI. His INR was high at 3.3. Despite dynamic ST segment changes, he could not receive IV platelet inhibitors because of his high INR. He was subsequently taken to the cath lab for immediate catheterization which showed significant lesions in the circumflex and native right coronary arteries. His LAD was occluded but fed by a severely degenerated vein graft shown above. A large filling defect with thrombus was also seen. Despite these changes, flow into the LAD was normal. Grafts to the circumflex and RCA were occluded. His ejection fraction was 25%.

Treatment options included sending him for a second heart bypass. He also has significant lung disease making this a less attractive option. The remaining options include catheter revascularization. One option involves catheter thrombectomy with Angiojet. This is an excellent option but this device was not available. The option chosen and shown above was to anticoagulate the patient with Heparin for several days. When the INR fell back into the normal range, Tirofiban was started. After 24 hours, the patient returned to the cath lab where his circumflex lesion was easily stented. Then, the degenerated vein graft was successfully stented using two overlapping stents. 5 Days of antithrombotic and antiplatelet therapy proved successful in improving the filling defect seen on the first angiogram and allowing successful completion of the stent procedure. The vein graft was pretreated with Intracoronary adenosine. Had it been available, a distal protection device to prevent embolization into the native vessel could have been used.