Editorial Comment

Reconstructing Diseased VeinGrafts—Great Potential RaisesOld Issues

David A. Clark, MD

Clinical Professor of MedicineStanford UniversityStanford, California

The deterioration of saphenous vein grafts has long been adiscouraging sequela of coronary bypass surgery. Initial failure of asmall percentage of bypasses is generally due to technical problemswith the anastomoses, or to small caliber, poor run-off recipientvessels. The later deterioration of bypasses with resulting return ofmyocardial ischemia is generally a combination of intimal hypertro-phy, atherosclerosis, and thrombosis which presents the interven-tional cardiologist faced with an attempt to repair the diseased graftin an effort to avoid a second or third open chest bypass procedurewith a technically difficult and dangerous challenge.

The use of balloon angioplasty to repair diseased vein bypassgrafts was described early and often, and in the early days ofpercutaneous transluminal coronary angioplasty (PTCA), it wasfelt that diffusely diseased grafts should be considered a relativecontraindication to angioplasty [1]. The anatomically diffuse andfriable material that often filled these bypass conduits was felt notto be amenable to the compression techniques of angioplasty inboth the short and long term. The danger of distal embolization wasenough to discourage even the most fearless interventionalists fromperforming a dangerous procedure that would probably only delaythe inevitable need for repeat surgery as other areas of the graftgradually deteriorated.

With the advent of stents, better initial and long-term resultswere achieved, and with the addition of abcibimax to the intrapro-cedural therapeutic regimen, less distal embolization occurred andbetter long-term results were achieved.

The current report by Dr. Stefanadis and associates [2] builds ontheir previous experience using autologous coated stents in avariety of situations [3–5]. The article describes the successfulreconstruction of a truly diffusely diseased old graft utilizing bothconventional stenting and freshly prepared autologous vein andartery coated stents. The coated stent technique is infinitely morecomplex than conventional stenting but may be significantly betterin terms of both initial results and long-term patency of thereconstructed graft.

The reported multiple-stenosed, thrombus-filled totally occludedgraft would cause even the bravest interventionalist to question theadvisability of treating this graft with conventional balloon orstent-assisted angioplasty. The use of distal conventional stents to

assure run-off and the placement of autologous vein and arterycoated stents to cover the proximal thrombotic region provide anexcellent control study of the initial and 6 month angiographicappearance of the reconstructed graft. The superior angiographicappearance of the graft in the coated stent segment as well as thestrikingly smaller loss of the initially dilated diameter in the coated(1.4%) vs. the conventional stent segments (34.32%) suggest that,if larger series confirm this superior result, autologous coated stentsmay be the treatment of the future for diffusely diseased bypassgrafts.

The problems raised with the technique will probably parallelthe skill and logistical problems that faced angiographers and theirinstitutions in the early days of conventional angioplasty. How doesan interventionalist become trained to harvest arteries and veinsand to sew them onto the stent? Will vascular surgeons be availableto do this, or will they be willing to train interventionalists toperform the procedures (see Turf Wars, latest chapter)? Willinterventionalists have the surgical skills necessary to learn thisnew technique, and who will determine if those skills exist? Andfinally, will the catheterization laboratory be flexible (and sterile)enough to accommodate the prolonged procedural time necessaryto perform the task?

Hopefully, if this innovative procedure to reconstruct bypassgrafts proves to be a superior alternative to repeat open chestbypass surgery, the issues that the new procedure raises will besolved (as the issues raised initially by coronary angioplasty wereovercome) to provide the patient with a beneficial, less traumaticmethod to treat the presence of myocardial ischemia caused by thedeterioration of bypass grafts.

REFERENCES

1. Clark DA: ‘‘Coronary Angioplasty.’’ New York: Wiley-Liss, 1991,pp 69–72.

2. Stefanadis C, Toutouzas K, Tsiamis E, Vlachopoulas C, Kallika-zaros I, Stratos C, Toutouzas P: Total reconstruction of a diseasedsaphenous vein graft by means of conventional and autologoustissue-coated stents. Cathet Cardiovasc Diagn (in press).

3. Stefanadis C, Toutouzas K, Vlachopoulos C, Tsiamis E, Kallika-zaros I, Stratos C, Vavurankis M, Toutouzas P: Autologous veingraft-coated stent for treatment of coronary artery disease. CathetCardiovasc Diagn 38:159–70, 1996.

4. Stefanadis C, Tsiamis E, Vlachopoulos C, Toutouzas K, Stratos C,Kallikazaros I, Vavuranakis M, Toutouzas P: Autologous veingraft-coated stents for the treatment of thrombus-containing coro-nary artery lesions. Cathet Cardiovasc Diagn 40:217–222, 1997.

5. Stefanadis C, Tsiamis E, Vlachopoulos C, Toutouzas K, Stratos C,Kallikazaros I, Giatrakos N, Toutouzas P: Arterial autologousgraft-stent for treatment of coronary artery disease: A new tech-nique. Cathet Cardiovasc Diagn 40:302–307, 1997.

Catheterization and Cardiovascular Diagnosis 43:322 (1998)

r 1998 Wiley-Liss, Inc.