Successful angioplasty of a chronically occluded saphenous vein graft using a prolonged urokinase infusion from the brachial route

A 68-year-old man who presented with unstable angina had had cardiac bypass surgery 12 years earlier and successful angioplasty of a native circumflex lesion 18 months previously. Repeat catheterization showed a widely patent angioplasty site but interval closure of a saphenous vein graft to a large marginal branch that was totally occluded proximally. A stress test revealed significant myocardial ischemia. Severe peripheral vascular disease with known bilateral iliac artery occlusions mandated a brachial approach. Because of his high risk for repeat cardiac surgery, it was elected to attempt saphenous graft angioplasty following a prolonged urokinase infusion. After an infusion of urokinase for 36 hr, antegrade flow was restored and angioplasty was carried out successfully on a discrete mid-graft legion. Subsequent stress testing showed resolution of the ischemia. There were no vascular complications.