Transcatheter therapy of thrombotic-occlusive lesions in saphenous vein grafts

Pharmacotherapy During Saphenous Vein Graft Intervention

Coronary revascularization using saphenous vein grafts is an important treatment modality for patients with severe coronary artery disease. Percutaneous intervention of these grafts is often the best option for patients who develop severe stenosis of the vein grafts. Use of adjunctive glycoprotein IIb/IIIa inhibitors does not confer added benefit with ischemic endpoints as compared with heparin alone, but it increases the risk of bleeding. Bivalirudin used as the primary anticoagulant lowers the risk of bleeding. No-reflow frequently complicates vein graft interventions but can be treated with vasoactive agents such as calcium channel blockers, adenosine, and nitroprusside.

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.

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

This study assessed safety of the distal occlusion washout (DOW) method for prevention of no-reflow during stenting of degenerated saphenous vein grafts (SVGs). The DOW method involves protection of distal native coronary circulation with an occlusive balloon during the pretreatment and washout steps prior to stenting. Outcomes of stenting of 23 grafts in 21 patients after pretreatment with the DOW method were evaluated. The mean graft age was 7.4 +/- 4.3 years. The mean treated lesion length was 53 +/- 28 mm. Total occlusions were treated in 6 grafts and thrombotic lesions in 10 nontotally occluded grafts. One non-Q-wave MI and one acute stent thrombosis were observed. No deaths, Q-wave MIs, or subacute thromboses occurred. Follow-up in 18/21 (85.7%) patients at 28 +/- 8 weeks demonstrated target graft revascularization in 1 (5%) patient. The DOW method prevented clinically significant no-reflow in all 23 degenerated SVGs stented.