Apixaban for the treatment of saphenous vein graft thrombosis presenting as unstable angina: a case report
© The Author(s). 2017
Received: 9 November 2016
Accepted: 17 March 2017
Published: 4 April 2017
Saphenous vein graft thrombosis can present as unstable angina. However, percutaneous coronary intervention for saphenous vein graft lesions poses a high risk of slow flow related to the procedure. Here we present the utilization of the novel oral anticoagulant, apixaban, in the treatment of unstable angina with extensive saphenous vein graft thrombus, leading to considerable thrombus resolution and eliminating the need of percutaneous coronary intervention.
A 72-year-old man with 3-vessel coronary artery bypass graft surgery using a saphenous vein graft and a left internal mammary artery, performed 25 years earlier, presented at our hospital with recurrent chest tightness. The echocardiography showed regional hypokinesis of the post-lateral wall with moderate left ventricular dysfunction, which had not been previously confirmed. Coronary angiography showed obstruction of the saphenous vein graft with a large thrombus burden. The left internal mammary artery was patent and other natives were the same as they had been 3 years ago. He was diagnosed with unstable angina due to acute saphenous vein graft thrombosis. Instead of percutaneous coronary intervention, he was treated with apixaban 5 mg twice a day. The angiography 3 weeks after starting apixaban showed considerable resolution of the thrombus and opening of the saphenous vein graft.
Apixaban could become a viable treatment option for acute saphenous vein graft thrombosis.
KeywordsApixaban Saphenous vein graft thrombosis Unstable angina
Saphenous vein graft (SVG) occlusion with thrombus formation is a substantial cause of acute coronary syndrome, including unstable angina, in patients undergoing coronary artery bypass graft (CABG) surgery . Percutaneous coronary intervention (PCI) is considered to be a first-line option . However, SVG angioplasty is associated with frequent periprocedural complications due to distal embolization [3–5]. Therefore, the therapeutic approach in unstable angina due to SVG thrombosis is still controversial. Here we describe a case demonstrating that apixaban, a novel oral anticoagulant, was effective for unstable angina due to SVG thrombosis and might be an alternative to PCI.
A saphenous venous graft (SVG) to right coronary artery was almost occluded with a large thrombosis burden. (MOV 7060 kb)
After 3 weeks with apixaban treatment, the SVG was opened. (MOV 4498 kb)
We found 2 important clinical issues. First, apixaban can quickly remove thrombosis of SVG and can help avoid PCI. Second, apixaban safely operates with a relatively low risk of bleeding complications compared with warfarin.
SVG thrombosis is called the “deep vein thrombosis” of the heart and its possible pathophysiology is assumed to be the same as that of deep vein thrombosis ; therefore, novel oral anticoagulants (NOACs) were effective for SVG thrombosis, as shown in the present case. In addition, the resolution of the thrombus with apixaban was rapid (within just 3 weeks). Therefore, apixaban could become a viable option for acute SVG thrombosis presenting as unstable angina, where PCI has risk for distal embolization and rapid thrombus resolution is required.
The second important point is that apixaban is relatively safe with a low risk of bleeding complications. Compared with warfarin, which failed to show high SVG primary patency rates  and increased major bleeding , apixaban has lower rates of major bleeding [9, 10]. It should be mentioned that among NOACs, apixaban alone reveals not only significantly reduced major bleeding but also greater net clinical benefit in patients with venous thromboembolism . Therefore, it is remarkable that apixaban was also effective in patients with acute SVG thrombosis, as shown in the present case, although we should not ignore the fact that apixaban itself is associated with a potential risk of bleeding.
We used apixaban instead of PCI for the treatment of acute SVG thrombosis presenting as unstable angina. This novel approach, which is likely safer than warfarin and may be safer and more effective than mechanical approaches, deserves further study as a treatment for acute SVG thrombosis.
Coronary artery bypass graft
Left anterior descending artery
Left internal mammary artery
Novel oral anticoagulants
Percutaneous coronary intervention
Saphenous vein graft
The authors thank Dr. Miyasaka Masaki from Sendai Kousei Hospital for his critical appraising the manuscript.
No funding was received for this study.
Availability of data and materials
The datasets generated and analyzed during the current study are not publicly available due to the patient’s privacy but are available from the corresponding author on reasonable request.
MS, TI and TO collected and analyzed the data. MS wrote the article. TI had the idea for the article and revised it critically. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Informed consent or substitute was obtained from the patient for this study.
Ethics approval and consent to participate
Clinical description of this case report was approved by Institutional Review Board of the Sendai Kousei Hospital.
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