1
|
Nardone EW, Madsen BM, McCarey MM, Fischman DL, Ruggiero NJ, Walinsky P, Vishnevsky A, Savage MP. Percutaneous coronary intervention of totally occluded coronary venous bypass grafts: An exercise in futility? World J Cardiol 2021; 13:493-502. [PMID: 34621494 PMCID: PMC8462047 DOI: 10.4330/wjc.v13.i9.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/27/2021] [Accepted: 07/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) of diseased saphenous vein grafts (SVG) continues to pose a clinical challenge. Current PCI guidelines give a class III recommendation against performing PCI on chronically occluded SVG. However, contemporary outcomes after SVG intervention have incrementally improved with distal protection devices, intracoronary vasodilators, drug-eluting stents, and prolonged dual antiplatelet therapy.
AIM To reassess the procedural and long-term outcomes of PCI for totally occluded SVG with contemporary techniques.
METHODS This was a retrospective observational study conducted at a single university hospital. The study population consisted of 35 consecutive patients undergoing PCI of totally occluded SVG. Post-procedure dual antiplatelet therapy was continued for a minimum of one year and aspirin was continued indefinitely. Clinical outcomes were assessed at a mean follow-up of 1221 ± 1038 d. The primary outcome was freedom from a major adverse cardiac event (MACE) defined as the occurrence of any of the following: death, myocardial infarction, stroke, repeat bypass surgery, repeat PCI, or graft reocclusion.
RESULTS The study group included 29 men and 6 women with a mean age of 69 ± 12 years. Diabetes was present in 14 (40%) patients. All patients had Canadian Heart Classification class III or IV angina. Clinical presentation was an acute coronary syndrome in 34 (97%) patients. Mean SVG age was 12 ± 5 years. Estimated duration of occlusion was acute (< 24 h) in 34% of patients, subacute (> 24 h to 30 d) in 26%, and late (> 30 d) in 40%. PCI was initially successful in 29/35 SVG occlusions (83%). Total stent length was 52 ± 35 mm. Intraprocedural complications of distal embolization or no-reflow occurred in 6 (17%) patients. During longer term follow-up, MACE-free survival was only 30% at 3 years and 17% at 5 years.
CONCLUSION PCI of totally occluded SVG can be performed with a high procedural success rate. However, its clinical utility remains limited by poor follow-up outcomes.
Collapse
Affiliation(s)
- Evan W Nardone
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, United States
| | - Brandon M Madsen
- Department of Anesthesiology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Melissa M McCarey
- Jefferson Clinical Research Institue, Thomas Jefferson University, Philadelphia, PA 19107, United States
| | - David L Fischman
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, United States
| | - Nicholas J Ruggiero
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, United States
| | - Paul Walinsky
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, United States
| | - Alec Vishnevsky
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, United States
| | - Michael P Savage
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, United States
| |
Collapse
|
2
|
Xenogiannis I, Zenati M, Bhatt DL, Rao SV, Rodés-Cabau J, Goldman S, Shunk KA, Mavromatis K, Banerjee S, Alaswad K, Nikolakopoulos I, Vemmou E, Karacsonyi J, Alexopoulos D, Burke MN, Bapat VN, Brilakis ES. Saphenous Vein Graft Failure: From Pathophysiology to Prevention and Treatment Strategies. Circulation 2021; 144:728-745. [PMID: 34460327 DOI: 10.1161/circulationaha.120.052163] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Saphenous vein grafts (SVGs) remain the most frequently used conduits in coronary artery bypass graft surgery (CABG). Despite advances in surgical techniques and pharmacotherapy, SVG failure rates remain high, often leading to repeat coronary revascularization. The no-touch SVG harvesting technique (minimal graft manipulation with preservation of vasa vasorum and nerves) reduces the risk of SVG failure, whereas the effect of the off-pump technique on SVG patency remains unclear. Use of buffered storage solutions, intraoperative graft flow measurement, careful selection of the target vessels, and physiological assessment of the native coronary circulation before CABG may also reduce the incidence of SVG failure. Perioperative aspirin and high-intensity statin administration are the cornerstones of secondary prevention after CABG. Dual antiplatelet therapy is recommended for off-pump CABG and in patients with a recent acute coronary syndrome. Intermediate (30%-60%) SVG stenoses often progress rapidly. Stenting of intermediate SVG stenoses failed to improve outcomes; hence, treatment focuses on strict control of coronary artery disease risk factors. Redo CABG is associated with higher perioperative mortality compared with percutaneous coronary intervention (PCI); hence, the latter is preferred for most patients requiring repeat revascularization after CABG. SVG PCI is limited by high rates of no-reflow and a high incidence of restenosis during follow-up. Drug-eluting and bare metal stents provide similar long-term outcomes in SVG PCI. Embolic protection devices reduce no-reflow and should be used when feasible. PCI of the corresponding native coronary artery is associated with better short- and long-term outcomes and is preferred over SVG PCI, if technically feasible.
Collapse
Affiliation(s)
- Iosif Xenogiannis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.).,Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Greece (I.X., D.A.)
| | - Marco Zenati
- Division of Cardiac Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, MA (M.A.Z.)
| | - Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, MA (D.L.B.)
| | - Sunil V Rao
- Durham VA Medical Center, Duke University, NC (S.R.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C.).,Hospital Clinic of Barcelona, Barcelona, Spain (J.R.-C.)
| | - Steven Goldman
- Sarver Heart Center, University of Arizona, Tucson (S.G.)
| | - Kendrick A Shunk
- San Francisco VA Medical Center, University of California, San Francisco (K.S.)
| | | | - Subhash Banerjee
- VA North Texas Health Care System, University of Texas Southwestern Medical School, Dallas (S.B.)
| | | | - Ilias Nikolakopoulos
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.).,Yale School of Medicine, Yale New Haven Hospital (I.N., E.V.)
| | - Evangelia Vemmou
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.).,Yale School of Medicine, Yale New Haven Hospital (I.N., E.V.)
| | - Judit Karacsonyi
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.)
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Greece (I.X., D.A.)
| | - M Nicholas Burke
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.)
| | - Vinayak N Bapat
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.)
| | - Emmanouil S Brilakis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern, MN (I.X., I.N., E.V., J.K., M.N.B., V.N.B., E.S.B.)
| |
Collapse
|