After Judkins [1] reported his method of selective coronary arteriography in the late 1960s, his transfemoral approach became the most commonly performed technique because of its ease of use. With this change came reports of embolic complications [2], which if resulting in stroke or myocardial infarction could only be treated supportively. Fortunately we learned to reduce these untoward events by meticulous technique and systemic heparinization.
Sandoval and Laufer [3] in the preceding case report describe a therapeutic option -urgent intervention with both intravenous and intra-arterial r-tPA in a patient with an acute stroke developing during invasive thrombolysis of a thrombosed aortocoronary saphenous vein bypass graft. Although this case report is an unusual complication that I have fortunately not seen before, a similar intervention was reported in this journal by O Β¨zbek et al. [4] in 1991. A symptomatic cerebral embolus occurring during left ventriculography in a patient with left ventricular mural thrombus was successfully treated by urgent selective intra-arterial r-tPA. There was significant improvement in neurological deficit by 4 hours and complete recovery in 24 hours. They concluded that ''... immediate selective thrombolysis may be helpful in managing cerebroembolic complications during left heart catheterization and should be considered in cases where such a diagnosis seems to be likely possible.'' Thrombolysis for stroke, now frequently referred to as a ''brain attack'' by our neurological colleagues, did not become accepted until the last few years [5]. Although direct intra-arterial thrombolysis is considered the primary nonsurgical intervention for peripheral thromboembolism, this technique is not the clear choice for acute myocardial infarction and stroke. The recent development of microcatheters for neural and peripheral embolotherapy has led to their use for infusion therapy, especially thrombolysis with direct intrathrombus administration in small distal vessels. In the United States, r-tPA is only approved for intravenous usage in acute myocardial infarction and stroke. Urokinase is approved for intravenous use in pulmonary embolism and acute myocardial infarction. It is the only thrombolytic drug approved for intraarterial infusion and that for intracoronary use in acute coronary artery thrombosis. However, in myocardial infarction, direct intraarterial thrombolysis is rarely attempted except for clotted venous