Saphenous Vein Graft Intervention
Saphenous Vein Graft Intervention
Saphenous Vein Graft Intervention
•Class I:
Patients with early ischemia (usually within 30 days) after CABG. (LOE: B)
•Class IIa:
1. Patients with ischemia occurring 1 to 3 years post-operatively and preserved
LV function with discrete lesions in graft conduits. (LOE : B)
2. Disabling angina secondary to new disease in a native coronary circulation.
(If angina is not typical, the objective evidence of ischemia should be
obtained). (LOE : B)
3. Patients with diseased vein grafts > 3 years following CABG. (LOE : B)
Recommendations for PCI With Prior CABG
•Class III:
1. PCI to chronic total vein graft occlusions. (LOE : B)
2. Patients with multivessel disease, failure of multiple SVGs, and
impaired LV function. (LOE : B)
• Note:
The status of the LAD and its graft significantly influences the selection process.
(because lack of survival benefit of repeat surgery to treat non-LAD ischemia.)
• One year after C.A.B.G,
• patients begin to
develop new
atherosclerotic plaques Native
in the graft conduit
or Coronary
• show atherosclerotic
progression in the
Interventions
native coronary
arteries.
• Treatment of protected left
main disease. Approaches to
• Recanalization of an old
total occlusion
native vessel
OR sites in post-
• native artery via venous or
arterial grafts.
bypass patients
Intervention of The Aorto-ostial Lesion
• There is a question about need of prior debulking followed by stenting or
stenting alone of the aorto- ostial lesion.
• In a study by Ahmed et al. for both groups of patients with or without
prior debulking, the TLR rate after one year was similar at 19%.
• The technical concern during PCI of large and bulky aorto-ostial lesion
is the antegrade and retrograde embolization.
• There is distal protective device for antegrade embolization, but there
is none for retrograde embolization.
• 1-3yr after surgery, patients begin to develop
atherosclerotic plaques in the SVG.
• after 3 years, these plaques appear with Saphenous
increased frequency.
• At the early stage, dilation of the distal Vein Graft
anastomosis can be accomplished with little
morbidity and good long-term patency (80–
(SVG)
90%). Intervention
• Dilation of the proximal and mid-segment of the
vein graft was highly successful at 90%, with a s
low rate of mortality (1%), Q-wave MI, and
CABG(2%).
• The rate of non-Q-wave MI was 13%.
Intervention in degenerated saphenous vein grafts:
• The lesions that are bulky or associated with thrombus are considered to be
high-risk.
• The complications include distal embolization, no-reflow, abrupt closure,
and perforation.
• Different approaches were devised because there is much to lose from
the standpoint of distal embolization causing non-Q MI and increasing
long-term mortality.
• In the case of perforation of SVG, usually there is contained perforation
rather than cardiac tamponade due to the extrapericardial course of the
grafts.
Rheolytic Thrombectomy
Dissolution and removal of clots from
coronary and peripheral arteries is
achieved by the creation of a flow-
mediated vacuum in the vicinity of the
treated lesion.
SVG’s.
3.0%
1.7%
0%
Death MI MACE
20.0
% Angiojet
In this high risk population, Urokina
se
15.0
procedural success and hospital course %
13.6
without a major adverse cardiac event 10.0
% 11.8
%
were achieved with the Angiojet %
Incidence
inhibitor bail-out in patients 1
treated with the X-Sizer, 0
(%)
suggesting a reduction in 5
periprocedural complications. 1. 0. 1. 1.
0 3 8 5
MACE rates at 30 days were 0
similar in both groups Cardiac MI TVR MACE
Death
There was a significantly lower
incidence of large
postprocedural MI at 30-day
follow-up among patients
treated with the X-Sizer device.
• In general, the X-Sizer system is
more effective in removing
thrombus and atheromatous
debris.
• While the AngioJet system was effective
only in the removal of fresh thrombus,
and not the friable, grumous vein graft
material or older organized thrombi
Prevention of distal embolisation
Distal protection devices.
Proximal protection devices.
SAFER Trial – Comparison of
PercuSurge to Routine Stenting in SVG’s
801 Patients Randomized
20 30 Day MACE
16.5%
Reduced 42%
P<0.001
9.6%
%
0
Routine
PercuSurge
• The 800 patient multicenter
randomized SAFER trial
demonstrated a 50% reduction in in-
hospital adverse events with
PercuSurge distal protection during
SVG stenting, when compared to
stenting without protection
• Preliminary experiences with the
PercuSurge in AMI patients
undergoing percutaneous in AMI
patients undergoing percutaneous
PercuSurge
System
Advantages Disadvantages
Captures smaller Transient occlusion
particles and
Long “parking”
“humoral” mediators segment
Frequently applicable Side branches
unprotected
Two operators
Filter wire
.
• In Filter wire-type devices, An emboli
entrapment net is mounted on a 0.014"
guidewire and expanded distally to the
lesion.
• Intervention is then performed over the
guidewire.
• Filters do not block distal blood flow when
first deployed unlike occlusive devices.
• Dislodged material is caught by the distal
filter, which is then closed and retracted
only at the end of the procedure.
Fire Trial: Randomized
BSC/EPI Filter vs. PercuSurge
inSVGPCI650 patients in 65 sites
FW GW
TIMI 3 Flow 95.7% 97.7%
Device Success 95.5% 97.2%
Death 0.9% 0.9%
MI 9.0% 10.0%
QMI 0.9% 0.6%
30 day MACE 9.9% 11.6%
Conclusion: FW not inferior to GW
Stone et al. J Am Coll Cardiol 2003; 41: 43A
• These devices occlude flow into the vessel
using a balloon on the tip of or just the tip
of catheter
PROXIMAL • Two proximal occulusion catheters are in
OCCLUSIO use:
N DEVICES • Proxis catheter
• Kerberos embolic protection system
Proxis In Vessel