Successful mechanical thrombectomy of a large venous graft thrombus burden using a novel device in an unusual way: a case report

Mechanical thrombectomy (mTE) is an established standard of care for selected patients with acute ischaemic stroke. However, in the cardiac equivalent—acute coronary syndrome—current guidelines do not recommend mTE. This is primarily based on trials showing no mortality benefit from routine thrombus aspiration, along with an increased risk of stroke.

A 76-year-old male with known three-vessel coronary artery disease and a history of coronary artery bypass grafting presented to our emergency department with a non-ST-elevation myocardial infarction. Angiography revealed a subacute occlusion of the saphenous vein graft to the posterior descending artery. An initial attempt at percutaneous coronary intervention of the native right coronary artery was unsuccessful due to severe calcification. Following successful recanalization of the vein graft, a high thrombus burden persisted despite manual aspiration and tirofiban bolus with continuous infusion, as confirmed by repeat angiography at the next day. Consequently, we performed mTE using a stent retriever system, achieving complete thrombus removal. This was followed by stent implantation in the vein graft, with final angiography demonstrating full restoration of distal perfusion. This case highlights the value of mTE as a bailout strategy in cases with a substantial thrombus burden, particularly in vein grafts, and underscores the potential of a stepwise approach starting with aspiration and escalating to mTE if required.

This case illustrates that in selected cases of myocardial infarction with a substantial thrombus burden, mTE may help achieve TIMI-III flow and reduce the risk of distal embolization. Moreover, it demonstrates the feasibility of delivering a stent retriever through an aspiration catheter, thereby enabling a less invasive, resource-efficient, and potentially safer procedural strategy without the need for a dedicated microcatheter.