Intracerebral hemorrhage complicating urokinase infusion into an occluded aortocoronary bypass graft

Adjunctive abciximab improves outcomes during recanalization of totally occluded saphenous vein grafts using transluminal extraction atherectomy

Degenerative disease of aortocoronary saphenous vein grafts is a major cause of late morbidity and mortality in patients after coronary bypass surgery. We previously described a technique for recanalization of totally occluded grafts using extraction atherectomy (TEC) as a primary modality. While success was comparable to overnight urokinase, distal embolization, no-reflow, and non-Q myocardial infarction were common. Recently, abciximab has been used adjunctively in angioplasty and stenting with a reduced incidence of periprocedural complications. In order to determine whether abciximab can reduce the incidence of distal embolization, no-reflow, and myocardial infarction during TEC in totally occluded saphenous vein grafts, we compared patients treated with adjunctive abciximab with control subjects not receiving the drug. Male patients with previous coronary bypass surgery, class III-IV angina, and totally occluded saphenous vein grafts serving a vascular territory with ischemia not approachable by standard catheter-based techniques underwent TEC with or without adjunctive abciximab. Recanalization of the graft was achieved in 8/10 (80%) of subjects without abciximab, but complete success was achieved in only 5/10 (50%). In contrast, all procedures in the abciximab group were completely successful, without embolization or no-reflow. Our results suggest that TEC with adjunctive abciximab may be a highly effective approach for management of totally occluded saphenous vein grafts.

One-year follow-up of recanalization of totally occluded aortocoronary saphenous vein grafts using transluminal extraction atherectomy

Recanalization of totally occluded aortocoronary saphenous vein grafts with extraction atherectomy was successful in 80% of patients. Whereas all patients with unsuccessful procedures were dead at 1 year, 75% of those with successful procedures are alive and free of events.

Extraction atherectomy for the recanalization of totally occluded aortocoronary saphenous vein grafts

This report describes the successful treatment of totally occluded aortocoronary saphenous vein grafts with percutaneous transluminal extraction atherectomy (TEC) in three patients with severe angina and high reoperative surgical risk. The method presented here may provide an alternative to overnight urokinase infusion or repeat surgery in high risk patients.

Antithrombotic and thrombolytic therapy in patients undergoing coronary artery interventions: a review

The controlled arterial injury that occurs with balloon angioplasty and other coronary interventions is characterized by evanescent endothelial denudation and vascular disruption. As a consequence, platelet activation occurs at the treated site, and there is a risk of thrombotic occlusion. This risk is heightened by several factors including unstable clinical presentation, lesion complexity, deep injury, and dissection. Aspirin has been shown to unquestionably reduce, although not eliminate, acute complications and is now part of the routine periprocedural regimen. Heparinization with more intense anticoagulation than is conventionally used is also standard treatment and is initiated before vessel instrumentation. Adjunctive thrombolysis is rarely necessary unless refractory thrombus precedes or complicates the procedure. However, thrombolysis may have a role in the treatment of saphenous vein graft obstructive lesions in which guide wire- or catheter-induced distal thromboembolization may cause infarction in spite of successful graft recanalization. In contrast to their success in the periprocedural phase of coronary interventions, anticoagulants and a wide variety of platelet active agents have been ineffective in reducing the 30% to 40% incidence of restenosis. Only 7E3, which targets the final common pathway of platelet aggregation by irreversibly blocking the IIb/IIIa receptor, has been shown to decrease the 6-month clinical event rate after balloon angioplasty, possibly by a surface pacification mechanism. This suggests that newer more potent antiplatelet and anticoagulant agents may also find a role in the long-term management of these patients.