Can direct stenting in selected saphenous vein graft lesions be considered an alternative to percutaneous intervention with a distal protection device?

In-hospital outcomes and usage of embolic protection devices in percutaneous coronary intervention for coronary artery bypass grafts: Insights from a Japanese nationwide registry

OBJECTIVES

We evaluated the in-hospital outcomes of percutaneous coronary intervention (PCI) for bypass graft vessels (GV-PCI) compared with those of PCI for native vessels (NV-PCI) using data from the Japanese nationwide coronary intervention registry.

METHODS

We included PCI patients (N = 748,229) registered between January 2016 and December 2018 from 1,123 centers. We divided patients into three groups: GV-PCI (n = 2,745); NV-PCI with a prior coronary artery bypass graft (pCABG) (n = 23,932); and NV-PCI without pCABG (n = 721,552).

RESULTS

GV-PCI implementation was low, and most cases of PCI in pCABG patients were performed in native vessels (89.7%) in contemporary Japanese practice. The risk profile of patients with pCABG was higher than that of those without pCABG. Consequently, GV-PCI patients had a significantly higher in-hospital mortality than NV-PCI patients without pCABG after adjusting for covariates (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.66-3.36, p < .001). Of note, embolic protection devices (EPDs) were used in 18% (n = 383) of PCIs for saphenous vein grafts (SVG-PCI) with a significant variation in its use among institutions (number of PCI: hospitals that had never used an EPD vs. EPD used one or more times = 240 vs. 345, p < .001). The EPDs used in the SVG-PCI group had a significantly lower prevalence of the slow-flow phenomenon after adjusting for covariates (OR 0.45, 95% CI 0.21-0.91, p = .04).

CONCLUSION

GV-PCI is associated with an increased risk of in-hospital mortality. EDP use in SVG-PCI was associated with a low rate of the slow-flow phenomenon. The usage of EPDs during SVG-PCI is low, with a significant variation among institutions.

Percutaneous coronary interventions on vein graft bifurcation lesions presenting as an acute coronary syndrome

Interventions on graft bifurcation lesions are uncommon, especially in the setting of acute coronary syndromes (ACS). We described three cases of graft bifurcation intervention where we tailored our approach based on lesion characteristics, anatomy, and angulation to achieve excellent angiographic and clinical outcomes. In case 1, shared ostia of saphenous vein graft (SVG) to Diagonal (D) and Radial graft to Obtuse Marginal (OM) was severely stenosed. We prioritized the radial arterial graft as it is known to have a longer patency rate over a totally occluded SVG of an undetermined period. We performed provisional stenting of the ostium of the radial artery and balloon angioplasty of the SVG ostium, while stenting the body of the SVG. In case 2 (bifurcation lesion at the anastomosis of SVG to D1 and sequential jump graft to OM), we utilized a V stenting strategy after an embolization protection device (EPD) was deployed in the branch with a suitable landing zone. Kissing balloon dilatation of both the branches was performed both pre- and poststenting. In case 3 (bifurcation lesion at SVG to OM and Sequential "T" graft to diagonal), there was >90% angulation between both the grafts. We used "T" stenting strategy in this case. At 2-year follow-up, patients had no major adverse cardiovascular events since and remained symptom free.

Long-Term Clinical Outcomes of Percutaneous Coronary Intervention in Saphenous Vein Grafts in a Low to Middle-Income Country

Background Revascularization of saphenous vein grafts (SVGs) is challenging and debated for the last few decades. The percutaneous revascularization of SVGs was reported to have poorer long-term outcomes than native coronary artery revascularization. Purpose We aim to study the peri-procedural complications and long-term outcomes of the percutaneous revascularization of SVGs in a low-middle-income country. Methods In this retrospective study, we included 110 patients who underwent percutaneous revascularization from January 2011 to March 2020 and followed them retrospectively for long-term outcomes and major adverse cardiovascular events. Results The mean age was 71 ±9, and 81% were male. The most common reason for the presentation was non-ST segment elevation myocardial infarction (NSTEMI) (46%). The mean follow-up period of the study was 48±27 months. The most common comorbidity was hypertension (86%). A drug-eluting stent (80%) was placed in most of the patients, followed by a bare-metal stent (BMS) (14%) and percutaneous balloon angioplasty (POBA) (6%). We did not find any significant difference in major adverse cardiac events (MACE) (P=0.48), target vessel revascularization (TVR) (p=0.69), and target lesion revascularization (TLR) (p=0.54) with drug-eluting stent (DES) as compared to either BMS or POBA. The mean period from coronary artery bypass grafting (CABG) to SVG percutaneous coronary intervention (PCI) was 15± 5.5 years. Multivariate Cox regression analysis showed that an acute coronary syndrome (ACS) event, stroke, and female sex were independently associated with MACE. Conclusion The long-term outcomes of SVG PCI are not affected by the types of stents. Female gender, ACS, and stroke are the independent predictors of MACE after SVG PCI, and statin therapy has a positive impact on the long-term outcomes of SVG PCI.

Outcomes Following Percutaneous Coronary Intervention in Non-ST-Segment-Elevation Myocardial Infarction Patients With Coronary Artery Bypass Grafts

Background There are limited data on outcomes of patients with previous coronary artery bypass graft (CABG) presenting with non-ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI). We compare clinical characteristics and outcomes in non-ST-segment-elevation myocardial infarction patients undergoing PCI with or without prior CABG surgery in a national cohort. Methods and Results We identified 205 039 patients with non-ST-segment-elevation myocardial infarction who underwent PCI between 2007 and 2014 in the British Cardiovascular Intervention Society database. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 3 groups: group 1, PCI in native coronary arteries and no prior CABG (n=186 670); group 2, PCI in native arteries with prior CABG (n=8825); group 3, PCI in grafts (n=9544). Patients in group 2 and 3 were older and had more comorbidities and higher mortality at 30 days (group 2, 2.6% and group 3, 1.9%) and 1 year (group 2, 8.29% and group 3, 7.08%) as compared with group 1 (1.7% and 4.87%). After multivariable analysis, no significant difference in outcomes was observed in 30-days mortality (odds ratio; group 2=0.87 [CI, 0.69-1.80; P=0.20], group 3=0.91 [CI, 0.71-1.17; P=0.46]), in-hospital major adverse cardiovascular event (odds ratio: group 2=1.08 [CI, 0.88-1.34; P=0.45], group 3=0.97 [CI=0.77-1.23; P=0.82]), and in-hospital stroke (odds ratio: group 2=1.37 [CI, 0.71-2.69; P=0.35], group 3=1.13 [CI, 0.55-2.34; P=0.73]; group 1=reference). Conclusions Patients with prior CABG are presenting with non-ST-segment-elevation myocardial infarction and treated with PCI had more comorbid illnesses, but once these differences were adjusted for, prior CABG did not independently confer additional risk of mortality and major adverse cardiovascular event.

Current State of the Art in Approaches to Saphenous Vein Graft Interventions

Saphenous vein grafts (SVGs), used during coronary artery bypass graft surgery for severe coronary artery disease, are prone to degeneration and occlusion, leading to poor long-term patency compared with arterial grafts. Interventions used to treat SVG disease are susceptible to high rates of periprocedural MI and no-reflow. To minimise complications seen with these interventions, proper stents, embolic protection devices (EPDs) and pharmacological selection are crucial. Regarding stent selection, evidence has demonstrated superiority of drug-eluting stents over bare-metal stents in SVG intervention. The ACCF/AHA/SCA American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions guidelines recommend the use of EPDs during SVG intervention to decrease the risk of periprocedural MI, distal embolisation and no-reflow. The optimal pharmacological treatment for slow or no-reflow remains unclear, but various vasodilators show promise.

The impact of diabetes mellitus on long-term clinical outcomes after percutaneous coronary saphenous vein graft interventions in the drug-eluting stent era

OBJECTIVES

We aimed to compare early and late clinical outcomes in diabetic and nondiabetic patients who underwent saphenous vein graft (SVG) percutaneous coronary interventions (PCI) with the use of drug-eluting stents (DES).

BACKGROUND

Patients with diabetes mellitus are shown to have less favorable outcomes after SVG intervention with the use of bare metal stents. In the DES era, the impact of diabetes mellitus on restenosis and clinical outcomes post-SVG intervention is not clearly defined.

METHODS

From our institutional PCI registry database, we retrospectively analyzed 477 consecutive patients with prior coronary artery bypass graft surgery undergoing SVG PCI with the implantation of DES stratified by the presence or absence of diabetes mellitus. The primary end-point was 1-year major adverse cardiac event (MACE) rate, defined as death, Q wave myocardial infarction, and target lesion revascularization.

RESULTS

Baseline clinical characteristics, including mean graft age (120 ± 77 vs. 131 ± 86 months, P = 0.14), were similar between groups, save for a higher prevalence of systemic hypertension and chronic renal insufficiency, and higher body mass index in the diabetic group. Among the 604 SVG lesions treated with DES, the angiographic and procedural characteristics were well matched between groups except for the higher rate of distal protection device use (32% vs. 29%, P = 0.007) in the diabetic group. The rates of 1-year MACE (21% vs. 15%, P = 0.12) and all-cause mortality (7.6% vs. 6.7%, P = 0.86) were similar between groups. After adjustment for the relevant clinical co-variables, diabetic status was not associated with the composite end-point.

CONCLUSION

In conclusion, DES, when used for the treatment of vein graft lesions, equate the short- and long-term outcomes between diabetic and nondiabetic patients, suggesting that DES should be considered the default stent in diabetic populations undergoing PCI for the treatment of SVG lesions.

Three-Year Outcomes Associated With Embolic Protection in Saphenous Vein Graft Intervention

Background—

Information is limited on contemporary use and outcomes of embolic protection devices (EPDs) in saphenous vein graft interventions.

Methods and Results—

We formed a longitudinal cohort (2005–2009; n=49 325) by linking National Cardiovascular Data Registry CathPCI Registry to Medicare claims to examine the association between EPD use and both procedural and long-term outcomes among seniors (65+ years), adjusting for clinical factors using propensity and instrumental variable methodologies. Prespecified high-risk subgroups included acute coronary syndrome and de novo or graft body lesions. EPDs were used in 21.2% of saphenous vein grafts (median age, 75; 23% women) and were more common in acute coronary syndrome (versus non–acute coronary syndrome; 22% versus 19%), de novo (versus restenotic; 22% versus 14%), and graft body lesions (versus aortic and distal anastomosis; 24% versus 20% versus 8%, respectively). EPDs were associated with a slightly higher incidence of procedural complications, including no reflow (3.9% versus 2.8%; P <0.001), vessel dissection (1.3% versus 1.1%; P =0.05), perforation (0.7% versus 0.4%; P =0.001), and periprocedural myocardial infarction (2.8% versus 1.8%; P <0.001). By 3 years, death, myocardial infarction, and repeat revascularization occurred in 25%, 15%, and 30% of cases, respectively. EPD use was associated with a similar adjusted risk of death (propensity score–matched hazard ratio, 0.96; 95% confidence interval, 0.91–1.02), myocardial infarction (propensity score–matched hazard ratio, 1.00; 95% confidence interval, 0.93–1.09), and repeat revascularization (propensity score–matched hazard ratio, 1.02; 95% confidence interval, 0.96–1.08) in the overall cohort and high-risk subgroups.

Conclusions—

In this contemporary cohort, EPDs were used more commonly among patients with high-risk clinical indications, yet there was no evidence of improved acute- or long-term outcomes. Further prospective studies are needed to support routine EPD use.

Early and midterm major adverse cardiac events in patient with saphenous vein graft using direct stenting or embolic protection device stenting

Background:

The treatment of an occluded saphenous vein graft (SVG) with percutaneous coronary intervention may encounter major adverse cardiac events (MACE). MACE rates have been reduced significantly by using the embolic protection device (EPD).

Objectives:

The aim of this study was to clarify the risks and the benefits of embolic protection devices.

Patients and Methods:

In a prospective, non-randomized observational study, patients aged 33 to 85 years old who underwent elective percutaneous coronary intervention due to SVG stenosis at our tertiary care center were enrolled between 2009 and 2011. The incidence rates of adverse events, including MACE, were obtained during the patients’ hospitalization and at 30-day and 6-month follow-up. MACE included death, Q-wave and non-Q-wave myocardial infarction, in-stent thrombosis, target lesion revascularization, and target vessel revascularization.

Results:

From 150 patients enrolled to the study, 128 (85.3%) patients underwent direct stenting and the rest underwent the EPD procedure. In-hospital MACE occurred in 17.2% of the patients in the direct stenting group versus only 9.1% in the EPD group (P = 0.530). MACE incidence was gradually increased at one and 6-month follow-up periods in the direct stenting group (19.5% and 21.9%, respectively), and remained unchanged in the EPD group (9.1% at six-month follow-up). Multivariate logistic regression model showed that the stenting procedure type could not predict early and midterm MACE with the presence of baseline characteristics as cofounders.

Conclusions:

Despite the considerable lower early and midterm MACE rates, numerically following the EPD procedure compared to direct stenting, the difference in the MACE rates between the two groups was not significant.

Current application and bioavailability of drug-eluting stents

INTRODUCTION

Drug-eluting stents (DES) were developed to reduce the restenosis rate of bare metal stents (BMS) and comprises three main components: i) a metallic scaffold; ii) an antiproliferative drug to reduce or abolish the formation of the neointima; and iii) the polymer, which both enables and controls drug elution into the vessel wall. Over the years, growing evidence has been reported on the safety and efficacy for different indications of DES.

AREAS COVERED

Since the introduction of first-generation DES, the technology has been refined, including changes in the alloy, stent design, polymer, drug and drug dose. In 2014, we will usher in a third generation of DES, which will include biodegradable polymers, polymer-free DES and bioabsorbable scaffolds.

EXPERT OPINION

In recent years, considerable progress has been made in DES development. The BMS platform set the groundwork for the development of metal scaffolds with drug-eluting capability to prevent restenosis. Importantly, extensive research has shown long-term safety and efficacy of the newer generation DES. Available data suggest that DES can be safely and effectively used to treat a complex subset of patients and lesions, including patients presenting with acute myocardial infarction, lesions in saphenous vein grafts, chronic total occlusions, multivessel disease, small vessels, long lesions and bifurcations. One of the safety targets is to eliminate stent thrombosis.

Current percutaneous treatment strategies for saphenous vein graft disease

Coronary artery bypass graft surgery remains one of the most widely performed surgical procedures in North America and aortocoronary saphenous vein grafts (SVG) are the most frequently used surgical conduits. SVG disease (SVGD) remains the leading cause of symptomatic coronary artery disease postcoronary artery bypass graft. When optimal medical therapy is ineffective, repeat surgery is associated with higher mortality combined with less favorable clinical and angiographic results, thus percutaneous revascularization on SVG is currently the standard of care for the revascularization of SVGD. Balloon angioplasty, bare metal stents, polytetrafluoroethylene-covered stents, and drug-eluting stents have been extensively investigated for SVG interventions. Multiple recent randomized trials and meta-analyses have confirmed the pathophysiologic and clinical differences between SVGD and coronary artery disease. Decisions such as patient selection, premedication, stent, and protection device characteristics should be carefully considered to achieve optimal procedural and clinical results. Acute coronary syndromes due to SVG involvement, chronic total occlusions, retrograde approaches, and SVG perforation management are newer fields requesting additional research.

Synergy between direct coronary stenting technique and use of the novel thin strut cobalt chromium Skylor™ stent: the MACE in follow up patients treated with Skylor stent [MILES Study]

BACKGROUND:

Despite significant improvements in stent platform, currently available bare-metal stents (BMS) are still associated with restenosis. Thin-strut design cobalt-chromium alloys hold the promise of improving results of BMS, especially when implanted with direct technique. We performed an observational study to appraise outcomes of the novel Skylor™ stent, stratifying outcomes according to stenting technique.

METHODS and RESULTS:

We included all consecutive patients undergoing coronary stenting with Skylor™ at 2 centers between 2006 and 2009. The primary end-point was the long-term rate of major adverse cardiac events (MACE, i.e. death, myocardial infarction (MI), coronary artery bypass grafting (CABG) or target vessel revascularization (TVR)). As pre-specified analysis, we compared patients undergoing direct stenting versus those stent implantation following pre-dilation. A total of 1020 patients were included (1292 Skylor™ stents), with procedural success obtained in 99%. Comparing patients undergoing direct stenting (66%) versus pre-dilation (34%) at 16±7 months of follow-up, MACE had occurred in, respectively, 8% versus 14% (p=0.001), with death in 1% versus 2% (p=0.380), MI in 1% versus 2% (p=0.032), CABG in 0.2% versus 2% (p=0.012), and TVR in 6% versus 9% [p=0.071]. Even at multivariable analysis with propensity adjustment, direct stenting was associated with significantly fewer MACE [hazard ratio 0.60 [0.38-0.93], p=0.024].

CONCLUSIONS:

This observational study suggests the presence of a beneficial synergy between direct coronary stenting technique and use of the novel thin-strut cobalt-chromium Skylor™ stent in real-world patients undergoing PCI.

Optimal Stenting in Saphenous Vein Graft Intervention

Percutaneous interventions of (usually degenerated) saphenous vein grafts (SVG) are associated with higher risk of distal embolization and worse clinical outcomes, including target vessel revascularization, myocardial infarction, and death, as compared with percutaneous coronary intervention of native coronary arteries. Embolic protection devices have demonstrated value in reducing the risk of embolization and postprocedural enzyme elevation after SVG interventions. Frequently, however, such devices are not used or cannot be used. As a result, novel stenting strategies intended to decrease the risk of periprocedural myocardial infarction seem to play a major role in enhancing the results following SVG interventions.

Percutaneous intervention of a thrombotic-occluded saphenous vein graft successfully treated using the undersized stent approach to prevent distal embolization

Percutaneous intervention carries a higher risk of distal embolization and poorer outcome in saphenous vein grafts (SVG) than in native coronary vessels. Embolic protection devices (EPD) have demonstrated value in decreasing the risk of embolization and post-procedural enzymes elevation after SVG intervention. Although there is ample evidence to support the routine use of EPD for SVG interventions, frequently those devices are not utilized or cannot be used because of technical reasons. As we previously reported, the "undersized stenting" approach seems to be an attractive strategy when EPD cannot be used. We present a case with severe SVG degeneration that illustrates the feasibility of this strategy.

Endovascular stenting of an extracranial-intracranial saphenous vein high-flow bypass graft: Technical case report

Background:

The authors describe a case of endovascular stenting of an extracranial–intracranial saphenous vein high-flow bypass graft in the management of a complex bilateral carotid aneurysm case.

Case Description:

A 43-year-old woman was admitted with progressive visual field restriction and headache. Imaging studies revealed bilateral supraclinoid carotid aneurysms. The right carotid aneurysm was clipped and the left one was treated by an endovascular procedure, after performing an internal carotid artery–middle cerebral artery (ICA-MCA) saphenous vein bypass graft. A few months following the bypass procedure, a 70–80% stenosis of the graft was discovered and treated endovascularly with a stenting procedure. Follow-up at 36 months after the first operation showed the patency of the venous graft and no neurological deficits.

Conclusions:

Endovascular stenting of the extracranial–intracranial saphenous vein high-flow bypass graft is technically feasible when postoperative graft occlusion is discovered.