Introduction: Primary percutaneous coronary intervention (PCI) of great saphenous vein (VSM) graft remains a challenge due high thrombotic burden causing poor acute and long-term angiographic results (1). Several strategies have been proposed for such cases, such as deferred stenting, covered stents and distal protection devices, all with unsatisfactory results.

Case report: 68-year-old male with multiple cardiovascular risk factors, known coronary artery disease (CAD) treated with PCI on left anterior descending artery (LAD) in 2007. and two VSM coronary-artery bypass grafts (CABG) on right coronary artery (RCA) and left circumflex artery (LCX) in 2008. has presented with inferior ST elevation myocardial infarction (STEMI) in 2016 due to thrombotic occlusion of VSM on RCA. Despite multiple successful thrombectomies, three covered stents (MGuard, all 3.5 mm) had to be implanted. Additionally, one 5.0 mm bare metal stent (BMS) has been implanted in severe stenosis proximal to the occlusion. During the entire intervention, two boluses of eptifibatide were given, with the final thrombolysis in myocardial infarction (TIMI 2) flow achieved (Figure 1). The LAD and VSM on second obtuse marginal artery (OM2) were patent, while LCX has been occluded. In 2020 the patient was treated for limb ischemia with combined surgical thrombectomy and percutaneous intervention. The patient again presents in 2022 with infero-postero-lateral STEMI. Emergent coronarography revealed occluded VSM on RCA and OM2, with patent LAD. The occlusion of VSM on RCA was tackled first without successfully recanalizing the artery after a few minutes. The PCI of VSM on OM2 immediately followed. After recanalization of the VSM, eptifibatide boluses were given, followed by thrombectomy, predilatation and one drug-eluting stent (DES) implantation (4.0 mm). Due to immense distal embolization in native arteries, VSM attachment on LCX has been dilatated with a 2.5 mm balloon with only modest success. The further intervention was deferred for the next day while the patient was placed on continuous eptifibatide infusion (Figure 2). The strategy resulted in modest flow improvement. On the second intervention, VSM attachment has again been dilated with a 3.0 mm balloon, and an additional 4.5 mm DES was implanted in stenosis proximal to the culprit lesion (Figure 3). Eptifibatide has been continued for additional 24 hours. At 3 months follow-up, the patient was free of symptoms, and coronarography revealed no signs of restenosis with better flow distally (Figure 4).

Conclusion: Although covered stents and deferred stenting provide satisfactory acute results after primary PCI of VSM, their long-term results remain uncertain.