A 73 year old woman presented with angina 22 years after saphenous vein grafts. All three grafts were in excellent condition, with the exception of a severe stenosis in the proximal portion of the circumflex graft (panel A). For elective percutaneous coronary intervention (PCI), a FilterWire distal protection device was deployed in the body of the graft before pre-dilatation with a 2.5 × 15 mm Maverick balloon. Aiming to minimise the risk of distal embolisation, a (self expanding nitinol) Symbiot polymer covered stent (4.0 × 20 mm) was deployed (panel B). These stents require post-inflation to optimise deployment. Following in-stent inflation (4.0 × 15 mm Extensor) a new filling defect (white arrow) was immediately apparent within the stent at its proximal end (panel C). Filling defects (white arrows) were also present within the FilterWire device (black arrows) (panel C). The in-stent debris was presumed to be material extruded from the proximal margin of the covered stent after high pressure inflation and was displaced to the FilterWire by multiple passages of a deflated balloon and a single further inflation. Recovered atherothrombotic debris is shown in panel D. The end angiographic result was excellent with normal flow (panel E).

This case demonstrates the potential for distal embolisation despite covered stent use, and further emphasises the importance of distal protection strategies in vein graft intervention.