Percutaneous coronary intervention (PCI) in saphenous vein grafts (SVGs) carries a substantial risk of no-reflow and major adverse cardiovascular events (MACE). Distal embolisation is a key contributory factor to poor outcome. A recent randomised controlled trial demonstrated a 42% reduction in MACE with the use of a distal protection device to prevent embolisation. A 71 year old man with previous bypass grafts was admitted with an acute coronary syndrome. Coronary angiography demonstrated severe proximal stenosis in the left anterior descending (LAD) vein graft (panel A). The remaining grafts were occluded.

PCI to the LAD graft was performed with adjunctive abciximab and a distal protection device (Filter Wire EX, Boston Scientific). The device consists of a 0.014 inch angioplasty guide wire incorporating a porous filter membrane (pore size 80 μm) suspended from a wire loop. Radio-opaque markers (arrows) are employed to position the filter beyond the target lesion. Panel B shows the location of the Filter Wire during stent deployment. PCI was carried out by direct stenting of the culprit lesion and post-dilatation with a non-compliant balloon. An excellent angiographic result was achieved (panel C). Examination of the protection device after removal (panels D and E) revealed multiple embolic particles captured within the filter, with appearances suggesting small platelet emboli (white), lipid-rich plaque debris (yellow), and acute thrombus (red). These images graphically illustrate the potential of protection devices to reduce distal embolisation during vein graft PCI.