Delayed stenting of a thrombotic saphenous vein graft after intravenous tirofiban pretreatment

Percutaneous intervention of thrombus containing lesion carries a high risk of periprocedural complications [1]. If the culprit lesion is a saphenous vein graft, thrombus burden is usually large [2]. Optimal treatment strategy for such situation is still not well-defined. We describe a staged approach with intravenous tirofiban infusion prior to stent implantation for the management of a large thrombus in a stenosed old vein graft. A 66-year-old man with a history of previous inferior MI, was admitted to our hospital because of recurrent episodes of chest pain at rest. Risk factors were hypertension, non-insulin-dependent diabetes and smoking. Eight years earlier he underwent a coronary angiography that revealed severe three-vessels disease. Coronary artery bypass graft was performed with a sequential saphenous vein graft to first diagonal and first marginal branch and a left internal mammary artery to left anterior descending coronary artery; the right coronary artery of small caliber, was not grafted. After four years the patient had a non ST-elevation myocardial infarction and underwent stenting of the circumflex artery. He remained asymptomatic for four years under medical therapy up to the current admission. On admission the ECG showed T wave inversion in lateral leads. There was a mild increase in total creatine kinase up to 270 IU/l. At coronary angiography the left internal mammary artery graft was patent with diffuse disease in the distal left anterior descending, the right coronary artery was occluded proximally with moderate in-stent restenosis of the