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

Combined mechanical and thrombolytic treatment for totally occluded bypass grafts

Totally occluded venous grafts are usually less amenable to mechanical reperfusion alone (for example percutaneous transluminal coronary angioplasty, PTCA) because of the large mass of thrombotic material within the graft. A combined approach using mechanical and thrombolytic treatment might therefore be more successful. Twenty one patients (20 males, one female) with a mean age of 64.5 (SD 5.6) years underwent angiography because of crescendo or unstable angina (n = 19) or myocardial infarction (n = 2) at a mean of 21.7 (18.6) days after onset of symptoms (range 1-60). All patients had had coronary artery bypass grafting (CABG) at a mean of 8.02 (4.02) years (range 0.3-13 years) before the current admission. At catheterisation, totally occluded venous bypass grafts to the left anterior descending coronary artery or diagonal (n = 10), marginal (n = 6), or right coronary artery (n = 5) were found. A combination of PTCA and thrombolytic treatment (in eight patients extended thrombolysis for 24 hours) was successful in reopening the venous graft in 16/21 patients (76.2%). Immediate complications included femoral haematoma (4), distal embolisation (3), and infection in one patient. Out of 13 patients catheterised within three months, two had reoccluded, seven had restenosis, while four had patent grafts. Recurrent PTCA (at least once more) was done in eight patients. At long term follow up of a mean of 26.7 (21.6) months (range 4-75 months), four patients were asymptomatic, eight still suffered from mild stable angina, while three had recurrent hospital admissions and needed a second coronary artery bypass. A combination of thrombolytic treatment and PTCA is a feasible and practised approach to recanalise recently occluded venous bypass grafts.

Intracoronary Doppler flow to monitor the results of selective saphenous vein graft thrombolytic therapy

Selective intracoronary thrombolytic therapy has recently been advocated as a technique to recanalize occluded coronary bypass grafts. We report a novel approach for monitoring the results of this treatment utilizing a coronary artery doppler flow guidewire. This approach may optimize the duration of thrombolytic treatment in these patients.

Efficacy of adjunctive thrombolytic therapy in percutaneous transluminal coronary angioplasty

Adjunctive thrombolysis has not been shown to improve angioplasty success or complication rates in elective angioplasty or myocardial infarction and may be detrimental in unstable angina. Thrombolysis of chronically occluded vessels achieves recanalization at a rate comparable to conventional angioplasty and is associated with a high rate of complications and limited long-term patency. Thrombolysis administered for thrombus or acute occlusion complicating angioplasty usually achieves coronary artery patency but is unable to forestall complications in many cases. A benefit of thrombolysis in reducing restenosis has not been conclusively demonstrated.

Intracerebral hemorrhage complicating urokinase infusion into an occluded aortocoronary bypass graft

Selective infusion of urokinase into occluded coronary bypass vein grafts is effective in restoring patency. We report the occurrence of intracerebral hemorrhage complicating an intra-graft urokinase infusion protocol. The patient had known cerebral vascular structural pathology without recent clinical complications. Caution with the use of thrombolysis in this setting is suggested.

Coronary thrombus: a novel catheter-based approach to treatment

The presence of coronary thrombus during intracoronary interventions increases the risk of complications during the procedure. We describe a novel approach to infusing thrombolytic agents selectively into a coronary artery utilizing a new low-profile perfusion balloon. This approach may add a useful new treatment for resistant intracoronary thrombi.

New treatment approach for chronic total occlusions of saphenous vein grafts: thrombolysis and intravascular stents

Balloon dilation of saphenous vein graft (SVG) occlusions has a lower success rate than angioplasty of native coronary arteries. To improve this outcome, a new therapy for chronic total SVG occlusions was developed. In three aortocoronary bypass graft patients with class III-IV angina and chronic occlusion of the SVGs to the left anterior descending artery (age of occlusions: 2-24 wk, age of graft 1-13 yr), standard recanalization was achieved with a guide wire and intracoronary urokinase infusion (0.5-1.0 million unit bolus followed by 100,000 IU/hr for 11-24 hr; mean infusion time: 19.7 hr). In each patient, a residual focal stenosis (average 82.5%) was successfully dilated and stented (single 4.0 mm Palmaz-Schatz in two patients and a 3.5 mm Strecker stent in the other). All patients had complete relief of symptoms and no sequelae. During a mean 7.7 mon follow-up, 6-mon arteriographic evaluation in two patients showed minimal intra-stent narrowing (26% and 34%). In the Strecker stent patient, the device proved too small for the vein graft, leading to an 89% stent stenosis found on follow-up arteriography at 5 mon. The stent was redilated successfully with a 5% residual narrowing. After urokinase recanalization of chronic total SVG occlusions, intravascular stents may improve the long-term results seen with conventional SVG angioplasty.

Acute myocardial infarction complicating urokinase infusion for total saphenous vein graft occlusion

Saphenous vein graft occlusions have been successfully treated with extended urokinase infusions. We report a case of myocardial infarction complicating this treatment. A review of reported cases suggests that this complication may not be uncommon. The optional drug, dose, and infusion technique for intra-graft lytic therapy has not been determined. The costs, risks, and difficulty of this technique may limit its application.

Prolonged intravenous urokinase infusion: an alternative pharmacologic approach in the treatment of thrombus-containing saphenous vein graft stenoses

A subtotally occlusive saphenous vein graft stenosis resolved after rapid intracoronary and prolonged intravenous urokinase infusion. Additional therapy was unnecessary, avoiding the attendant risks of saphenous vein graft angioplasty. Combined intracoronary and intravenous urokinase infusion should be considered prior to coronary angioplasty of saphenous vein graft stenoses, particularly when diffuse degeneration is present or the risk of underlying thrombus is high.