Novel distal occluder washout method for prevention of no-reflow during stenting of saphenous vein grafts

Mechanical protection of cardiac microcirculation during percutaneous coronary intervention of saphenous vein grafts

Saphenous vein bypass grafts permeability is one of the most important limitations of open heart surgery. The risks associated with surgical re-intervention are greater than those associated with the initial procedure. While native coronary arteries usually have fixed, fibrotic or calcified atherosclerotic plaques, the disease in the vein grafts contains soft material. When this material is compressed during percutaneous angioplasty, there is an unfavorable immediate outcome due to distal embolization of thrombus and plaque debris. In addition, the risk of post-procedure adverse events are higher when the grafts have a long time of implantation, due to a greater risk of branch occlusion or no-reflow at the adjacent microcirculation. The clinical consequence is a Non-Q-Wave Myocardial Infarction that is reflected in the increased serum cardiac enzymes. It is because of this complication that the distal protection devices were developed. The purpose of this paper is to review and discuss the current data on the distal protection devices available now for the treatment of degenerative saphenous vein graft disease. Currently, there are two distal protection devices approved in the United States: the Guardwire Balloon and Aspiration (Export) System and the Filter Wire EX. Other devices like the Triactiv System, Angioguard XP/ECW, DOW, MedNova Cardioshield, Medtronic-AVE DPD and the E-Trap Filter are still being studied. The first observational studies showed the safety and efficacy of the approved devices. A large randomized trial initially confirmed a significant decrease of in-hospital and 30-day cardiac adverse events, mainly Non-Q-Wave Myocardial Infarction, when angioplasty was performed with the assistance of the Guardwire System. Subsequently, another randomized study showed an equivalence between the Guardwire System and the Filter Wire EX. Distal protection devices have an acceptable performance, however, further technological improvements are warranted for a quick preparation, delivery and/or retrieval of these devices.

Resolution of refractory no-reflow with intracoronary epinephrine

Refractory no-reflow is associated with adverse outcomes in patients undergoing percutaneous coronary intervention. Charts were reviewed to identify 29 consecutive patients in whom intracoronary epinephrine was administered for refractory no-reflow. The effects of intracoronary epinephrine on coronary flow (TIMI grade), cardiac rhythm, and systolic blood pressure in the cardiac catheterization laboratory were assessed. Administration of intracoronary epinephrine (mean dose, 139 +/- 189 microg) resulted in significant improvement in coronary flow. After administration, TIMI 3 flow was established in 69% of patients. Overall, TIMI flow significantly increased (mean TIMI flow form 1.0 +/- 1.0 to 2.66 +/- 0.55; P = 0.0001). Intracoronary epinephrine resulted in significant but tolerable increase in heart rate (72 +/- 19 to 86 +/- 26 beats/min; P = 0.009), but no cases of acute dysrhythmia. These findings indicate that intracoronary epinephrine may exert salutary effects in patients suffering refractory no-reflow following elective or acute coronary interventions.

Distal occluder and rheolytic thrombectomy of a saphenous vein graft lesion with a large associated thrombus

Percutaneous intervention in thrombus-containing lesions is frequently associated with complications, including distal embolization and no-reflow. In saphenous vein bypass grafts (SVG), friable atheroma and associated thrombus make interventions particularly difficult. Distal protection strategies are in development, but complete protection with removal of all potentially embolic material is challenging. This case illustrates a novel technique using a distal occluder balloon and rheolytic thrombectomy followed by stent deployment to treat a SVG lesion. This combination therapy was technically feasible, resulted in no angiographic complications and normal creatine kinase levels throughout follow-up, and can be used during high risk SVG interventions.

Percutaneous transluminal therapeutic ultrasound for high-risk thrombus-containing lesions in native coronary arteries

We assessed the short-term outcome of percutaneous coronary ultrasound thrombolysis (CUT) for high-risk thrombus-containing lesions in native coronaries in the setting of acute coronary syndromes (ACS). Data were prospectively collected in a multicenter (n = 32) registry of consecutive ACS patients. The study population (n = 126) had mostly (84%) totally occluded vessels. The mean age of clot was 5.7 +/- 9.5 days (range, 0-60 days). CUT (41 kHz, 18 W) led to device success in 112 (89%) patients, with a residual stenosis of 69% +/- 20%. Adjunct PTCA or stenting was used in 97% of the patients. Procedural success was achieved in 124 (98%) patients, with a final residual stenosis of 6% +/- 10%. There were no major adverse clinical events during hospitalization. Ultrasound thrombolysis is a feasible procedure that offers a safe and probably effective adjuvant device solution for the treatment of high-risk, thrombus-containing lesions in the native coronary arteries.

Balloon occlusion and transluminal aspiration of saphenous vein grafts to prevent distal embolization

Distal embolization is a common complication of percutaneous intervention in saphenous vein grafts. This may lead to the "no reflow" phenomenon and subsequent myocardial infarction. We describe a case in which we occluded the distal portion of a saphenous vein graft with a balloon to prevent distal embolization, performed percutaneous transluminal coronary angioplasty, and then successfully aspirated the particulate debris with a Dorros/Probing catheter.