Combined mechanical and thrombolytic treatment for totally occluded bypass grafts

Totally occluded venous grafts are usually less amenable to mechanical reperfusion alone (for example percutaneous transluminal coronary angioplasty, PTCA) because of the large mass of thrombotic material within the graft. A combined approach using mechanical and thrombolytic treatment might therefore be more successful. Twenty one patients (20 males, one female) with a mean age of 64.5 (SD 5.6) years underwent angiography because of crescendo or unstable angina (n = 19) or myocardial infarction (n = 2) at a mean of 21.7 (18.6) days after onset of symptoms (range 1-60). All patients had had coronary artery bypass grafting (CABG) at a mean of 8.02 (4.02) years (range 0.3-13 years) before the current admission. At catheterisation, totally occluded venous bypass grafts to the left anterior descending coronary artery or diagonal (n = 10), marginal (n = 6), or right coronary artery (n = 5) were found. A combination of PTCA and thrombolytic treatment (in eight patients extended thrombolysis for 24 hours) was successful in reopening the venous graft in 16/21 patients (76.2%). Immediate complications included femoral haematoma (4), distal embolisation (3), and infection in one patient. Out of 13 patients catheterised within three months, two had reoccluded, seven had restenosis, while four had patent grafts. Recurrent PTCA (at least once more) was done in eight patients. At long term follow up of a mean of 26.7 (21.6) months (range 4-75 months), four patients were asymptomatic, eight still suffered from mild stable angina, while three had recurrent hospital admissions and needed a second coronary artery bypass. A combination of thrombolytic treatment and PTCA is a feasible and practised approach to recanalise recently occluded venous bypass grafts.