My approach to a SVG graft with total occlusion: Illustrated with a case

Management of a patient with acute coronary syndrome after coronary artery bypass grafting (CABG) is challenging. Increasing age, associated co-morbidities, and progressive deterioration in left ventricular function make the scenario even worse. The escalation of ongoing medical treatment is usually the first step. Re-CABG is often not an option. Then, this becomes a compelling situation for an interventional cardiologist to perform an intervention to relieve the symptoms and sometimes repeated interventions. Conventionally, two types of interventions are described in this situation, either the intervention on native coronaries or intervention on graft vessels. Percutaneous revascularization is associated with higher rates of in-stent restenosis, target vessel revascularization, myocardial infarction, and death compared with native coronary arteries. Use of embolic protection devices is a Class I indication to decrease the risk of distal embolization. Nonetheless, these devices are underused. Most evidence supports treatment with drug-eluting stents. We illustrate the management with a case. This case used a thrombus aspiration device prior to stent deployment in saphenous vein graft to get optimal results without any "slow-flow" or "no-flow.