Rivaroxaban as Therapy for Saphenous Venous Graft Failure due to Venous Outflow Mismatch

Background. Recurrent angina and long-term occlusion following coronary artery bypass graft surgery is often treated with percutaneous coronary intervention, a high-risk intervention for distal embolization. Here, we present the utilization of the novel oral anticoagulant, rivaroxaban, in the treatment of saphenous vein graft thrombosis with complete resolution of the thrombus secondary to graft outflow mismatch. Case Presentation. A 69-year-old man with triple coronary artery bypass grafting using a saphenous vein and left internal mammary artery, performed in 2017, presented at our hospital for recurrent angina. Coronary angiography revealed a patent LIMA to LAD and a large clot burden in the venous conduit to the first OM/terminal circumflex-theorized to be due to an outflow mismatch of the large saphenous vein to the native artery resulting in stasis. Instead of percutaneous coronary intervention, he was treated with rivaroxaban 20 mg once a day. The angiography 4 weeks after starting rivaroxaban showed complete resolution of the thrombus. Conclusion. Rivaroxaban could become a potential treatment option in thrombus reversal due to static venous flow with subsequent long-term patency of the graft. Additionally, its use may be indicated in the generalized prevention of VGF.