Intracoronary administration of GP IIb/IIIa inhibitors has been reported in some case reports and in several small studies with some benefits in percutenous coronary interventions (PCI). In the event of angiographic evidence of large thrombus as seen in stent thrombosis, slow- or no-reflow phenomenon and other thrombotic complications, use of GP IIb/IIIa inhibitors as bail-out therapy seems reasonable. It has also been demonstrated that low-dose intracoronary streptokinase given immediately after primary PCI limited infarct size and preserved left ventricular functions. However, it is not clear giving intracoronary fibrinolytic plus GP IIb/IIIa inhibitor in cases of high thrombotic burden. A sixty-eight year old man was diagnosed with acute coronary syndrome. He underwent CABG surgery in 2003. In 2012, a drug eluting stent was implanted in the mid-RCA. He had hypertension, hyperlipidemia and was current smoker. Echocardiography revealed a ejection fraction of 42%. Coronary angiography revealed 80% stenosis in proximal LAD, which was totally ocluded after D2. Cx artery was occluded after OM2 branch. There was a 50% stent restenosis in RCA followed by a distal lesion of 50-60 %. The LIMA to LAD graft was patent, the stumps of two occluded saphenous vein grafts were shown in aortagraphy. The saphenous vein graft to OM major artery was totally occluded with extensive thrombi (figure-1). Tirofiban was administered as an intracoronary bolus injection (10μg/kg over 3 min) followed by maintenance intravenous infusion at 0.15μg•kg–1•min–1 for 24 h. Additonally, a 10 mg of Alteplase (t-PA) diluted with 20 ml of saline and given through the guiding catheter within 3 minutes. Immediately after these medications, a TIMI III flow was achieved with a distal thrombotic saphenous venous graft lesion (figure 2). A post-hoc coronary intervention was planned, and the patient was followed up in coronary care unit. There was not any recurrent chest pain, dynamic ECG changes and hemodynamic instability during follow-up period. The patient was discharged with medications of ticagrelor, metoprolol, telmisartan, acetylsalicylic acid, atorvastatin and proton pomp inhibitor. One week later, the control angiography revealed a distal lesion in the saphenous venous graft which was treated with a 2.5×12 mm bare metal stent implantation after a balloon predilatation without any complication (figure 3). Our case provided favorable results for using of dual therapy with intracoronary thrombolytic and GP IIb/IIIa inhibitor in a saphenous venous graft intervention complicated by extensive thrombi.
