COMPLEX SEPHENOUS VEIN GRAFT PERCUTANEOUS CORONARY INTERVENTION : PREVENTION OF NO FLOW USING A MULTIMODAL PHARMACOLOGIC APPROACH - A CASE FROM NIZAMIYE HOSPITAL

Percutaneous coronary intervention (PCI) of degenerated saphenous vein grafts (SVGs) carries a high risk of distal embolization and no-reflow due to friable plaque and heavy thrombus burden.

A 60-year-old man with hypertension and prior four-vessel coronary artery bypass grafting 13 years earlier presented with exertional upper epigastric and back pain relieved by rest. Symptoms persisted despite gastrointestinal treatment. Exercise stress testing reproduced his symptoms with ischemic ECG changes. Coronary CT angiography demonstrated occlusion of the SVG to the obtuse marginal branch and severe proximal stenosis of the SVG to the right coronary artery (RCA). Coronary angiography confirmed a patent left internal mammary artery graft and SVG to the diagonal branch, an occluded SVG to the obtuse marginal branch, and severe thrombus-rich proximal SVG–RCA stenosis with TIMI I flow. The patient received aspirin, ticagrelor, unfractionated heparin, and high-intensity rosuvastatin/ezetimibe. Intracoronary verapamil, nitroglycerin, and tirofiban were administered before cautious low-pressure predilatation using a 2.0 × 20 mm semi-compliant balloon, followed by implantation of a 4.0 × 26 mm drug-eluting stent. Final angiography demonstrated TIMI III flow without clinically significant no-reflow.

In high-risk SVG PCI, a multimodal pharmacologic strategy combined with careful lesion preparation may reduce no-reflow and facilitate successful myocardial reperfusion.