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Dr D. SOOKUR
MBChB, MRCP (UK), MD (USA)
Interventional Cardiologist (Canada)
& Cardiac CT Specialist (USA)
Cardiac centre, Mauritius
EDUCATIONAL CONTENT ENDORSED BY EAPCI, A REGISTERED BRANCH
OF THE EUROPEAN SOCIETY OF CARDIOLOGY
Figure 1
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015 E
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The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
Saphenous vein graft disease Gabriel Maluenda, Pierfrancesco Agostoni, Pieter R. Stella, Paul Vermeersch, Itsik Ben-Dor, Lowell F.
Satler, Ron Waksman, Augusto D. Pichard
Background *Ischemic symptoms recur in 4-8% of patients/year following CABG. *Recurrence of symptoms can be attributed to progression of native vessel coronary disease (5%/year) and bypass conduit occlusion, particularly SVG failure (7% in week 1; 15-20% in first year; 1-2%/yr during the first 5-6 years, and 3-5%/yr in years 6-10 postop). *At 10 years postop, approximately half of all SVG conduits are occluded and only half of the remaining patent grafts are free of significant disease. 5-10% PCI case volume.
Alexander JH. JAMA 2005; 16;294(19):2446-2454
Widimsky P. Circulation 2004 30;110(22):3418-3423
Mauritian Context CABG in Mauritius for > 25 years
Aging saphenous vein grafts
1 % of PCI in Mauritius for SVG (v/s worldwide 10%)
Growing volume of PCI for SVG expected
More challenging
Specific graft lesion intervention subtypes and the related outcomes
Early ischaemia after CABG surgery (within the first 30 days) - early graft occlusion, usually thrombotic, occurs in up to 10% - 3% to 6% of patients develop clinically significant ischaemia - in symptomatic patients, 37% to 56% SVG are occluded on angiogram - PCI is recommended in the presence of clinical evidence of relevant ischaemia
Stenosis of the distal anastomosis - PCI has particularly good results, better than ostial and shaft location results
Chronic totally occluded SVG - related to poor short-term and long-term outcomes - native recanalisation is preferred if possible - PCI only justified in the presence of life-impaired symptoms or a large, jeopardised myocardium
Drug-eluting stents (DES) vs bare metal stents (BMS) to treat saphenous vein grafts
DES have shown to be more effective that BMS by reducing the rate of TLR
Initial concern about DES safety was raised by the long-term follow-up of a small-randomised trial
Long-term safety of DES is supported by a large amount of data coming from large real-world series
Strategies to prevent no-reflow in SVG interventions
Pharmacology - glycoprotein IIb/IIIa inhibitors increase the rate of bleeding without any apparent benefit - vasodalitors can improve angiographic results but do not appear to improve clinical outcomes
Covered stents - their use has been linked to worse outcomes in several randomised trials - use not recommended
Embolic protection devices - proven stategy that decreases periprocedural myocardial infarction and the no-reflow phenomenon - routine use is recommended in selected high-risk interventions - both proximal and distal protection devices should be available and used according to disease location in the graft itself
Direct and undersized stenting - alternative approach to prevent distal embolization
Acute myocardial infarction due to saphenous vein grafts
High related in-hospital mortality and poor long-term prognosis
Possible role of aspiration thrombectomy – especially in the presence of visible thrombus
Possible role of staged procedure after aggressive pharmacology approach
EDUCATIONAL CONTENT ENDORSED BY EAPCI, A REGISTERED BRANCH
OF THE EUROPEAN SOCIETY OF CARDIOLOGY
Figure 5
© 2
015 E
uro
pa D
igital &
Publis
hin
g. A
ll rig
hts
reserv
ed.
The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine
Saphenous vein graft disease Gabriel Maluenda, Pierfrancesco Agostoni, Pieter R. Stella, Paul Vermeersch, Itsik Ben-Dor, Lowell F.
Satler, Ron Waksman, Augusto D. Pichard
Recommended