A hypertensive and diabetic 72-year-old man with 3-vessel CABG surgery, SVG to the first diagonal branch of the left anterior descending artery (LAD) and to the obtuse marginal branch of the left circumflex artery (sequential grafting) and the left internal mammary artery (LIMA) to the distal LAD, performed 25 years earlier, presented at our hospital complaining of recurrent chest tightness over the past week. On physical examination, there were no remarkable findings. An electrocardiography showed a normal sinus rhythm at a rate of 78/min with a complete right bundle branch block, but no significant ST-T change was found compared with the findings of his previous electrocardiography. Regional hypokinesis of the post-lateral wall with moderate left ventricular dysfunction, which had not been previously confirmed, was also observed. Cardiac enzymes were not elevated. Coronary angiography showed the obstruction of SVG with a large thrombus burden (Fig. , Movie 1). Although LAD was chronically occluded from the ostium, there was no significant change compared with his condition 3 years ago. LIMA to LAD was patent, and other natives were the same as they had been 3 years ago. He was diagnosed with unstable angina due to acute SVG thrombosis. Instead of PCI, he was treated with apixaban 5 mg twice a day for 3 weeks in addition to aspirin 100 mg once a day, which was already being taken. We added only apixaban and not a P2Y12 inhibitor considering the high risk of bleeding and the mechanism of thrombotic occlusion. After coronary angiography had been performed and PCI was selected, we planned to load a P2Y12 inhibitor. The angiography 3 weeks after starting apixaban showed a considerable resolution of the thrombus and an opening SVG (Figure , Movie 2). The coronary flow of the final angiography almost reached TIMI grade 3 flow, and there was no significant stenosis in SVG. Therefore, we did not move on to PCI due to the fear of distal embolization. The rest of the patient’s stay in the hospital was uneventful, and he was discharged 1 week after the procedure.
A 75-year-old male patient known to have diabetes mellitus, hypertension, dyslipidemia, and coronary artery disease underwent coronary artery bypass graft surgery in 2004 left internal mammary artery to left anterior descending artery, saphenous vein graft to right coronary artery and a jump (Y) graft to obtuse marginal 1 and obtuse marginal 2 presented to the emergency department complaining of chest pain and shortness of breath for three days. He was admitted to the coronary care unit as acute coronary syndrome, non-ST elevation MI and started on ACS medication. ECG showed lateral ST-T wave changes and Troponin I was positive, 1.8 ng/ml. The echocardiogram showed moderate hypokinesis of posterlateral wall and the ejection fraction was 50%.\nOn the second day patient underwent a coronary angiogram, which showed a patent saphenous graft to the right coronary artery; patent left internal mammary artery to left anterior descending artery; and patent Y-graft to obtuse marginal 2 and thrombus in the saphenous graft to obtuse marginal 1 [].\nPercutaneous intervention was performed using a manual suction technique with a small pediatric microvena snare catheter 4F (ev3, Plymouth, Minnesota. USA). After manual suction few times the graft become clear [] and both small organized and fresh clots were removed [] and no angioplasty was done in this case. Patient was discharged from the hospital in a very stable condition in a few days.