Case Study Thrombus removal prior to recanalization in vein graft occlusion intervention Raymond Chi-Yan Fung and Man-Hong Jim Abstract A saphenous vein graft chronic total occlusion intervention is uncommonly performed, partly due to the high risk of distal embolization. We described a strategy in which after successful wiring of a saphenous vein graft chronic total occlusion, balloon dilatation was performed to create a blind sac within the lesion, followed by aspiration thrombectomy to remove all the dislodged debris. Thereafter, balloon dilatation and stenting were safely performed in the distal occluded segment, to achieve complete recanalization. Keywords Angioplasty, balloon, coronary, Coronary angiography, Coronary artery bypass, Coronary thrombosis, Saphenous vein, Stents Introduction Owing to depletion of side branches and lack of per- ipheral run-off, an occlusion in an aortocoronary saphenous vein graft (SVG) invariably leads to rapid accumulation of thrombus until it reaches the proximal and distal anastomoses. Any intervention in an occluded SVG runs a very high risk of dislodging the long column of thrombus, resulting in distal emboliza- tion and no reflow, which are associated with myocar- dial damage and worse clinical outcomes. 1 A novel strategy was devised to remove friable debris and reduce the thrombus load with the aim of minimizing distal embolization. Case report A 63-year-old man with history of 3-vessel coronary artery bypass grafting 18 years earlier presented with crescendo angina for 3 months. Coronary angiography showed a blockage in the native left circumflex and right coronary artery and their 2 corresponding SVG. An elective percutaneous intervention on the SVG and right coronary artery was performed through a left radial approach (Figure 1a). The SVG was intubated with a 6F Amplatz left 2 guiding catheter and wired with a 0.014-inch coronary wire supported by a micro- catheter. The entire long segment of occlusion, with the exception of a short segment at the distal exit site (Figure 1b), was dilated with a 2.5 Â 15-mm balloon inflated at 18 atmospheres. Aspiration thrombectomy was performed via a 6F Export Advance aspiration catheter (Medtronic, Inc., Minneapolis, MN, USA) passed into the blind dilated segments for several runs (Figure 1c). A large amount of thrombus and debris was removed from the catheter. The short distal occluded segment was dilated with the same angio- plasty balloon (Figure 1d). Thereafter, the SVG was completely recanalized (Figure 2a). Three Orsiro stents (3.0 Â 40 mm, 2.75 Â 40 mm, and 3.5 Â 30 mm; Biotronik AG, Bu¨lach, Switzerland) were deployed in- series over the entire length of the SVG. The stents were post-dilated with a 3.5-mm noncompliant balloon inflated at 14–20 atmospheres (Figure 1e). A final angiogram showed an excellent result with TIMI-3 flow (Figure 2b). Post-procedure troponin I was slightly raised at 0.54 ng mL 1 (normal <0.4 ng mL 1 ). Dual antiplatelet therapy was prescribed for 12 months. The patient remained asymptomatic 12 months later. Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2018 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492318776147 journals.sagepub.com/home/aan Cardiac Medical Unit, Grantham Hospital, Hong Kong Corresponding author: Man-Hong Jim, Cardiac Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Hong Kong, China. Email: jimmanh2002@yahoo.com