Abstract
Background: Percutaneous coronary intervention (PCI) for thrombotic saphenous vein graft (SVG) occlusion presenting as ST-segment elevation myocardial infarction (STEMI) carries a high risk of distal embolization, slow-flow, and no-reflow. Whether routine stent implantation is mandatory following successful thrombus reduction in selected SVG lesions remains uncertain. Case Presentation: A 70-year-old man with a history of coronary artery bypass grafting (CABG) and bioprosthetic aortic valve replacement presented with inferior STEMI complicated by cardiogenic shock due to acute thrombotic occlusion of an SVG to the right coronary artery (RCA). Repeated mechanical aspiration thrombectomy successfully restored TIMI 3 flow. Subsequent evaluation with intravascular ultrasound (IVUS) revealed a focal soft plaque with minimal residual thrombus. Following stepwise lesion preparation with a non-compliant balloon, residual stenosis was reduced to 30-40% without flow-limiting dissection. To eliminate the risk of stent-induced distal embolization and long-term graft failure, a stent-free revascularization strategy using a paclitaxel-coated balloon (DCB, 3.0 × 25 mm) was successfully executed. At the 5-month follow-up, the patient remained clinically stable without adverse cardiovascular events. Conclusions: Routine stenting may not be compulsory in selected thrombotic SVG lesions provided that adequate thrombus clearance, optimal lesion preparation, and intravascular imaging optimization are achieved. A stepwise stent-free approach incorporating aspiration thrombectomy, IVUS guidance, and selective DCB application provides a safe and effective individualized alternative in this high-risk scenario.
