Percutaneous Coronary Intervention of Saphenous Vein Graft

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Long-term results of percutaneous coronary intervention in no-touch vein grafts are significantly better than in conventional vein grafts

INTRODUCTION

Conventional vein grafts have a high risk of thrombosis and early atherosclerosis. Percutaneous coronary intervention (PCI) in conventional vein grafts is associated with a higher incidence of late adverse cardiac events. The aim of this study was to evaluate the long-term results after PCI in saphenous vein grafts (SVG) harvested with the no-touch technique compared to the conventional technique.

METHODS

This was a single-center, retrospective, cohort study, based on data from the Swedeheart register. The inclusion criterion was individuals who underwent CABG using different vein graft techniques between January 1992 and July 2020, and who required a PCI in SVGs between January 2006 and July 2020. The primary end point was long-term in-stent restenosis. The secondary endpoints were long-term major adverse cardiac events (MACE) and 1-year re-hospitalization rates. The associations between the graft types and the endpoints were evaluated using the Fine and Gray competing-risk regression analysis.

RESULTS

The study included 346 individuals (67 no-touch, 279 conventional). The mean clinical follow-up time was 6.4 years with a standard deviation of 3.7 years. The long-term in-stent restenosis rate for the no-touch grafts was 3.2% compared to 18.7% for the conventional grafts (p < .01), with a subdistribution hazard ratio (SHR) of 0.16 (p = .010). The long-term MACE rate was 27.0% in the no-touch group and 48.3% in the conventional group (p < .01) with a SHR of 0.53 (p = .017). The short-term results were similar in both groups.

CONCLUSIONS

Percutaneous coronary intervention in a no-touch vein graft was associated with statistically significantly fewer in-stent restenoses and MACE at long-term follow-up compared to a conventional SVG.

Recent Advances in the Treatment of Coronary In-Stent Restenosis

In-stent restenosis (ISR) remains the predominant cause of stent failure and the most common indication for repeat revascularization. Despite technological advances in stent design, ISR continues to pose significant challenges, contributing to increased morbidity and mortality among patients undergoing percutaneous coronary interventions. In the last decade, intravascular imaging has emerged as an important method for identifying the mechanisms behind ISR and guiding its treatment. Treatment options for ISR have expanded to include balloon angioplasty, cutting or scoring balloons, intravascular lithotripsy, atheroablative devices, drug-eluting stents, drug-coated balloons, surgical revascularization, and intravascular brachytherapy. The aim of the current review is to describe the classification and mechanisms of ISR, provide a comprehensive and updated overview of the evidence supporting different treatment strategies, suggest a management algorithm, and present insights into future developments in the field.

Trends in utilization and clinical outcomes with and without the use of distal filter wire embolic protection devices

BACKGROUND

Embolic protection devices were developed to reduce the risk of common complications encountered during percutaneous coronary intervention (PCI) of saphenous vein grafts, however, in the setting of contemporary multi-modality medical management, their overall efficacy has been called into question. This study aimed to assess the evolving utilization and clinical outcomes associated with distal filter wire embolic protection devices in saphenous vein PCI.

METHODS

Consecutive patients undergoing PCI to a saphenous vein graft in a registry were included. Peri-procedural and long-term outcomes including 12-month mortality and 30-day MACCE rates were compared between PCI using a distal filter wire embolic protection device and unprotected PCI.

RESULTS

From 2005 to 2020, a total of 753 patients underwent PCI to a saphenous vein graft with 256 using a distal filter wire embolic protection device. At one year, the use of a distal filter wire embolic protection devices was not associated with a decrease in mortality (4.7 % vs 5.4 %, p = 0.19) and there was no difference in 30-day MACCE rates between protected and unprotected saphenous vein PCI (3.1 % vs 5.8 %, p = 0.10).

CONCLUSION

In this 12-month analysis of saphenous vein graft PCI, there was no evidence that distal filter wire embolic protection devices improved short term post procedural or long-term mortality outcomes.

Primary percutaneous intervention in an unusual vessel using an unusual technique: a case report

Background

Primary percutaneous intervention (PPCI) of the saphenous vein graft (SVG) is associated with a high risk of distal embolization and no reflow, since SVG lesions are often very friable and have a large thrombotic burden. We report a case of successful PPCI of the SVG using guide catheter thrombectomy with novel double wire technique.

Case summary

A 60-year-old male with a past history of coronary artery bypass grafting presented with acute thrombotic occlusion of the SVG to the obtuse marginal graft. Despite appropriate pharmacotherapy (GPIIb/IIIa inhibitors) and thrombosuction, there was a large residual thrombus burden with poor distal flow. In the present case, we decided to perform guide catheter thrombosuction. An exchange length floppy 0.014' wire was passed alongside the pre-existing wire and the 6 Fr JR guide catheter was exchanged for a less traumatic 5 Fr JR guide catheter over the exchange wire. The first wire was kept distally in the vessel along the guiding catheter to maintain the access to the graft vessel. The 5 Fr JR guide catheter was slowly advanced over the wire to the distal portion of the graft, keeping the other wire in the distal portion of the graft to maintain access. A large amount of thrombus was aspirated and the patient improved dramatically.

Discussion

This double wire technique is an effortless and novel way to maintain access to the distal vasculature of the occluded artery, while the guide can be safely intubated deep into the coronary artery that helps in removing a very large amount of thrombus because of their larger internal lumen.

Single-Centre Registry Analysis of Patients Who Underwent Percutaneous Coronary Intervention on Their Coronary Bypass Grafts

Background

The study assessed the outcomes of patients undergoing percutaneous coronary intervention (PCI) to bypass grafts, focusing on all-cause mortality and target vessel failure (TVF) rates.

Methods

A single-centre registry analysis included 364 patients who underwent PCI on coronary bypass grafts between 2008 and 2019. The study analyzed all-cause mortality and TVF, which encompassed target lesion revascularization, target vessel revascularization, and medically treated occluded target graft post-PCI.

Results

The median age of the patients was 71 years (interquartile range: [IQR] 65-78), with 82.1% being male. Most patients (94.8%) received PCI on saphenous vein grafts, and the median graft age was 13.0 years (IQR: 8.4-17.6). Drug-eluting stents were used more frequently (54.4%) than bare-metal stents (45.6%), with a median stent diameter of 3.5 mm (IQR: 3-4) and length of 19 mm (IQR: 18-28). Outcome differences were not significant for PCI sites (aorto-ostial, graft body, anastomosis), use of drug-eluting stents, or use of protection devices. The 1-year mortality rate was 3.3%, whereas the combined rate of TVF or death was 20.3%. After 5 years, the mortality rate increased to 14.9%, and the combined TVF or death rate rose to 40.3%. Multivariable analyses revealed that chronic kidney disease was independently associated with mortality (hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.16-2.61, P = 0.007), whereas hypertension (HR 2.42, 95% CI 1.32-4.42, P = 0.004) and increased stent length (HR 1.01, 95% CI 1.00-1.02, P = 0.007) were independently associated with the TVF-or-mortality outcome.

Conclusions

Patients undergoing PCI to bypass grafts experience considerable adverse outcomes over a 5-year period, highlighting the need for further strategies in managing this high-risk population.

PCI for Flush Occluded Right Coronary Artery: Challenges and Techniques for Success

A 74-year-old man with prior coronary artery bypass surgery had a failing vein graft to the right coronary artery (RCA). He underwent retrograde chronic total occlusion recanalization of an ostial flush-occluded RCA facilitated by retrograde angioplasty at the aorto-ostial junction after failed retrograde electrocautery. The graft was then sacrificed. (Level of Difficulty: Advanced.).

For patients with prior coronary artery bypass grafting and recurrent myocardial ischemia, percutaneous coronary intervention on bypass graft or native coronary artery?-A 5-year follow-up cohort study

BACKGROUND

Real-world data on target vessel of percutaneous coronary intervention (PCI) for patients with prior coronary artery bypass grafting (CABG) was still limited.

HYPOTHESIS

A prospective cohort was examined to determine the frequency and outcomes of native coronary artery PCI versus bypass graft PCI in patients with prior CABG.

METHODS

A large-sample observational study enrolled a total of 10 724 patients with coronary artery disease (CAD) underwent PCI in 2013. Two- and five-year clinical outcomes were compared between graft PCI group and native artery PCI group in patients with prior CABG.

RESULTS

A total of 438 cases had CABG history in the total cohort. Graft PCI group and native artery PCI group accounted for 13.7% and 86.3%, respectively. The rates of 2- and 5-year all-cause death and major adverse cardiovascular and cerebral events (MACCE) showed no significant difference between the two groups (p > .05). Two-year revascularization risk was lower in graft PCI group than native artery PCI group (3.3% and 12.4%, p < .05), but 5-year myocardial infarction (MI) risk was higher (13.3% and 5.0%, p < .05). In multivariate COX regression models, graft PCI group was independently associated with lower 2-year revascularization risk (hazard ratio [HR]: 0.21; 95% confidence interval [CI]: 0.05-0.88; p = .033), but higher 5-year MI risk than native artery PCI group (HR: 2.61; 95% CI: 1.03-6.57; p = .042). Five-year all-cause death and MACCE risk showed no difference between the two groups in model.

CONCLUSIONS

In patients with prior CABG underwent PCI, patients in graft PCI group had higher 5-year MI risk than patients received native artery PCI. But, 5-year mortality and MACCE was not significantly different between graft PCI group and native artery PCI group.

Characteristics of Radial Artery Coronary Bypass Graft Failure and Outcomes Following Subsequent Percutaneous Coronary Intervention

BACKGROUND

When patients with prior coronary artery bypass grafting (CABG) undergo percutaneous coronary intervention (PCI), targeting the native vessel is preferred. Studies informing such recommendations are based predominantly on saphenous vein graft (SVG) PCI. There are few data regarding arterial graft intervention, particularly to a radial artery (RA) graft.

OBJECTIVES

The aim of this study was to report the characteristics of arterial graft stenoses and evaluate the feasibility of RA PCI.

METHODS

This study included 2,780 consecutive patients with prior CABG undergoing PCI between 2005 and 2018 who were prospectively enrolled in the MIG (Melbourne Interventional Group) registry. Data were stratified by PCI target vessel. RA graft PCI was compared with both native vessel (native PCI) and SVG PCI. Internal mammary graft PCI data were reported. The primary outcome was 3-year mortality.

RESULTS

Overall, 1,928 patients (69.4%) underwent native PCI, 716 (25.6%) SVG PCI, 86 (3.1%) RA PCI, and 50 (1.8%) internal mammary graft PCI. Compared with SVG PCI, the RA PCI cohort presented earlier after CABG, less frequently had acute coronary syndrome, and more commonly had ostial or distal anastomosis intervention (P < 0.005 for all). Compared with patients who underwent native PCI, those who underwent RA PCI were more likely to have diabetes and peripheral vascular disease (P < 0.001 for both) and to present with non-ST-segment elevation myocardial infarction (P = 0.010). The RA PCI group had no perforations or in-hospital myocardial infarctions, though no significant difference was found in periprocedural outcomes compared with either native or SVG PCI. No differences were found between RA PCI and either native or SVG PCI in 30-day outcomes or 3-year mortality.

CONCLUSIONS

Presenting and lesion characteristics differed between patients undergoing arterial compared with SVG PCI, implying a varied pathogenesis of graft stenosis. RA PCI appears feasible, safe, and where anatomically suitable, may be a viable alternative to native PCI.

Filter-based embolic protection device in saphenous vein graft percutaneous intervention: A case report

Saphenous vein grafts (SVGs) are commonly used in coronary artery bypass graft (CABG) surgery patients. However, SVGs are prone to degradation and occlusion, resulting in poor long-term patency. Percutaneous coronary intervention (PCI) for SVG has been one of the options to treat SVGs disease despite its challenges. Embolic protection device (EPD) use along with proper stent and medications are considered to minimize complications in this procedure. A 61-year-old man, with 4-vessel coronary artery bypass using SVGs and left internal mammary artery (LIMA) 11 years ago, presented with chest pain for more than 3 months. Coronary angiography showed severe stenosis of the SVG to PDA with two lesions, chronic total occlusion in SVG to OM and LIMA to LAD, with patent SVG to D1. He was admitted for elective PCI using drug-eluting stents and distal embolic filter. There were no problems observed, and the procedure was completed with successful stenting in SVG to PDA without any complications. The patient was discharged on dual-antiplatelet therapy along with his previous medication history. PCI is preferred over repeated CABG in high-risk patients, and EPD should be considered whenever technically possible to minimize the risk of distal embolization and thereby improve outcomes in SVG PCI.

Acute Coronary Syndromes Among Patients with Prior Coronary Artery Bypass Surgery

PURPOSE OF REVIEW

Acute coronary syndromes (ACS) often occur in individuals with prior coronary artery bypass graft surgery (CABG). Our goal was to describe the prevalence, clinical characteristics, prognosis, and treatment strategies in this group of patients.

RECENT FINDINGS

Studies demonstrate that both acute and long-term major adverse cardiovascular outcomes are increased in patients with ACS and prior CABG compared to those without CABG. Much of this risk is attributed to the greater comorbid conditions present in patients with prior CABG. Data regarding optimal management of ACS in patients with prior CABG are limited, but most observational studies favor an early invasive approach for treatment. Native vessel percutaneous coronary intervention (PCI), if feasible, is generally preferred to bypass graft PCI. Patients with ACS and prior CABG represent a high-risk group of individuals, and implementing optimal preventive and treatment strategies are critically important to reduce the risk.

Trends and Outcomes of Myocardial Infarction in Patients With Previous Coronary Artery Bypass Surgery

Data on myocardial infarction (MI) treatment in patients with previous coronary artery bypass grafting (CABG) is limited. We queried the Nationwide Readmissions Database to identify hospitalizations of patients with MI from 2016 to 2019. Among hospitalized patients presenting with MI, 10.3% had previous CABG. Patients with MI who had previous CABG were less likely to be revascularized than those without previous CABG for both ST-segment elevation MI (STEMI) (46.4% vs 68.4%) and non-ST-segment elevation MI (NSTEMI) (30.8% vs 36.7%). CABG was associated with a lower risk of death in NSTEMI patients (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.82 to 0.86), but a higher risk in STEMI patients (OR 1.06, 95% CI 1.01 to 1.13). Revascularization was associated with a lower risk of in-hospital death in patients with previous CABG presenting with STEMI (OR 0.30, 95% CI 0.26 to 0.35) and NSTEMI (OR 0.21, 95% CI 0.19 to 0.23).

Temporal Trends in Complex Percutaneous Coronary Interventions

Background

Accumulated experience combined with technological advancements in percutaneous coronary interventions (PCI) over the past four decades, has led to a gradual increase in PCI utilization and complexity. We aimed to investigate the temporal trends in PCI complexity and the outcomes of complex PCI (C-PCI) in our institution.

Methods

We analyzed 20,301 consecutive PCI procedures performed over a 12-year period. C-PCI was defined as a procedure involving at least one of the following: Chronic total occlusion (CTO), left main (LM), bifurcation or saphenous vein graft (SVG) PCI. Four periods of 3-year time intervals were defined (2008–10, 2011–2013, 2014–2016, 2017–2019), and temporal trends in the rate and outcomes of C-PCI within these intervals were studied. Endpoints included mortality and major adverse cardiac events [MACE: death, acute myocardial infarction (MI), and target vessel revascularization (TVR)] at 1 year.

Results

A total of 5,647 (27.8%) C-PCI procedures were performed. The rate of C-PCI has risen significantly since 2,017 (31.2%, p < 0.01), driven mainly by bifurcation and LM interventions (p < 0.01). At 1-year, rates of death, acute MI, TVR and MACE, were all significantly higher in the C-PCI group (8.8 vs. 5.1%, 5.6 vs. 4.5%, 5.5 vs. 4.0%, 17.2 vs. 12.2%, p < 0.001 for all, respectively), as compared to the non-complex group. C-PCI preformed in the latter half of the study period (2014–2019) were associated with improved 1-year TVR (4.4% and 4.8% vs. 6.7% and 7.1%, p = 0.01, respectively) and MACE (13.8% and 13.5% vs. 17.3% and 18.2%, p = 0.001, respectively) rates compared to the earlier period (2007–2013). Death rate had not significantly declined with time.

Conclusion

In the current cohort, we have detected a temporal increase in PCI complexity coupled with improved 1-year clinical outcomes in C-PCI.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Percutaneous coronary intervention of totally occluded coronary venous bypass grafts: An exercise in futility?

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.

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 intervention in saphenous vein grafts after coronary artery bypass grafting: a systematic review and meta-analysis

To investigate the results of percutaneous coronary intervention (PCI) in saphenous vein grafts after coronary artery bypass grafting (CABG). Design. MEDLINE, Embase, and the Cochrane library were searched for relevant articles published between 1 January 2000 and 29 February 2020. The PICO (population, intervention, comparison, outcome) model was applied in constructing the clinical question. Two independent researchers performed the literature search. Thirty-six articles were identified and subjected to a quality assessment. The primary outcomes of the meta-analysis were long-term in-stent restenosis and long-term major adverse cardiac events (MACE). Results. In-stent restenosis was 9.4% (95% CI: 4.2-14.7%) and MACE was 35.3% (95% CI: 27-43.7%) at mean time 2.7 ± 1.0 years. The secondary outcomes were the unsuccessful PCI rate (7.7%; 95% CI: 2.9-12.5%), 30-day MACE (4.3%; 95% CI: 2.5-6.1%), and 1-year MACE (15.5%; 95% CI: 11.7-19.3%). The use of drug-eluting stents resulted in better outcomes at least in term of in-stent restenosis, while the benefit of using embolic protection devices was questionable. Conclusions. PCI of a stenosed or occluded saphenous vein graft is a challenge for interventional cardiologists, and is still associated with relatively high rates of restenosis, MACE, and procedural failure. All efforts to enhance the results are warranted, including improved quality of the venous grafts used during CABG.

Meta-analysis Comparing Outcomes of Percutaneous Coronary Intervention of Native Artery Versus Bypass Graft in Patients With Prior Coronary Artery Bypass Grafting

Percutaneous coronary intervention (PCI) is common in patients with prior coronary artery bypass graft surgery (CABG), however the data on the association between the PCI target-vessel and clinical outcomes are not clear. We aimed to investigate long-term clinical outcomes of patients with prior CABG who underwent PCI of either bypass graft or native artery. We performed a systematic review and meta-analysis of observational studies comparing PCI of either bypass graft or native artery in patients with prior CABG. Twenty-two studies comprising 40,984 patients were included. The median follow-up duration was 2 (1 to 3) years. Compared with bypass graft PCI, native artery PCI was frequent (61% vs 39%) and was associated with lower major adverse cardiac events (MACE) (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.45 to 0.57, p <0.001), lower all-cause death (OR 0.65, 95% CI 0.49 to 0.87, p = 0.004), lower myocardial infarction (OR 0.56, 95% CI 0.45 to 0.69, p <0.001), and lower target vessel revascularization (TVR) (OR 0.62, 95% CI 0.51to 0.76, p <0.001). There was no significant difference in the early incidence of major bleeding or stroke between the 2 cohorts. In 6 studies involving 2,919 patients with ST-elevation myocardial infarction, there was no significant differences between the 2 cohorts. The increase in TVR risk with bypass graft PCI was associated with MACE. In conclusion, in observational studies involving patients with prior CABG, native artery PCI was associated with lower MACE, all-cause death, myocardial infarction, and TVR compared with bypass graft PCI at a median follow-up of 2 years. Native artery PCI might be considered the preferred treatment for bypass graft failure.

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.

Stent-Only Versus Adjunctive Balloon Angioplasty Approach for Saphenous Vein Graft Percutaneous Coronary Intervention: Insights From DIVA Trial

BACKGROUND

Direct stenting without pre-dilation or post-dilation has been advocated for saphenous vein graft percutaneous coronary intervention to decrease the incidence of distal embolization, periprocedural myocardial infarction, and target lesion revascularization.

METHODS

We performed a post hoc analysis of patients enrolled in the DIVA (Drug-Eluting Stents Versus Bare Metal Stents in Saphenous Vein Graft Angioplasty; NCT01121224) prospective, double-blind, randomized controlled trial. Patients were stratified into stent-only and balloon-stent groups. Primary end point was 12-month incidence of target vessel failure (defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization). Secondary end points included all-cause death, stent thrombosis, myocardial infarction, and target lesion revascularization during follow-up.

RESULTS

Of the 575 patients included in this substudy, 185 (32%) patients underwent stent-only percutaneous coronary intervention. Patients in the stent-only versus balloon-stent group had similar baseline characteristics and similar incidence of target vessel failure at 12-months (15% versus 19%; hazard ratio, 1.34 [95% CI, 0.86-2.08]; P=0.19). During long-term follow-up (median of 2.7 years), the incidence of definite stent thrombosis (1% versus 5%; hazard ratio, 9.20 [95% CI, 1.23-68.92]; P=0.0085), the composite of definite or probable stent thrombosis (5% versus 11%; hazard ratio, 2.52 [95% CI, 1.23-5.18]; P=0.009), and target vessel myocardial infarction (8% versus 14%; hazard ratio, 1.92 [95% CI, 1.08-3.40]; P=0.023) was lower in the stent-only group. Multivariable analysis showed that a higher number of years since coronary artery bypass grafting and >1 target saphenous vein graft lesions were associated with increased target vessel failure during entire follow-up, while preintervention Thrombolysis in Myocardial Infarction-3 flow was protective.

CONCLUSIONS

In patients undergoing percutaneous coronary intervention of de novo saphenous vein graft lesions, there was no difference in target vessel failure at 12 months and long-term follow-up in the stent-only versus the balloon-stent group; however, the incidence of stent thrombosis was lower in the stent-only group, as was target vessel myocardial infarction. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01121224.

Outcomes of primary percutaneous cardiac intervention for ST elevation myocardial infarction with a saphenous vein graft culprit

BACKGROUND

Patients treated with primary percutaneous coronary intervention (pPCI) for ST elevation myocardial infarction (STEMI) who have a history of coronary artery bypass grafting (CABG) are at high risk of adverse cardiovascular outcomes. Data on the risk of a saphenous vein graft (SVG)-infarct-related artery (IRA) compared to other culprit vessels are sparse.

METHODS

The study was based on a prospectively collected registry of 2,405 consecutive patients with STEMI attending a tertiary medical center in 2001-2017. Patients with an SVG-IRA (n = 172) were compared with patients with native vessel disease (n = 2,333) for mortality and major adverse cardiac events (MACE), which included death, myocardial infarction (MI), target vessel revascularization (TVR), and coronary artery bypass surgery (CABG) at 1 month and 3 years.

RESULTS

The SVG-IRA group was significantly older than the native vessel group (p = .05), with no between-group differences in rates of male patients (76 vs. 82%, p = .59), diabetes (24.2 vs. 26.2%, p = .73), and renal failure (18.8 vs. 9.2%, p = .25). Mortality was higher in the SVG-IRA group at 1 month (13.9 vs. 2.5%, p < .01) and 3 years (23.9 vs. 7.4%, p < .01). At 3 years, SVG-IRA was associated with the highest rates of MACE (55.6%), compared with native vessel disease. After correction for confounders, SVG-IRA remained an independent risk factor for MACE both at 1 month (HR-2.08, 95%CI 1.72-3.11, p < .01) and 3 years (HR-2.01, 95%CI 1.28-3.09, p < .01).

CONCLUSION

Among patients treated with pPCI for STEMI, outcomes are worse when the culprit is an SVG.

Impact of high on-treatment platelet reactivity on outcomes following PCI in patients on hemodialysis: An ADAPT-DES substudy

OBJECTIVES

We sought to compare clinical outcomes after percutaneous coronary intervention (PCI) in patients on versus not on hemodialysis (HD) and examine whether high on-treatment platelet reactivity (HPR) further impacts outcomes among patients on HD.

BACKGROUND

Both chronic kidney disease (CKD) and HPR are predictors of major adverse cardiac events (MACE) after PCI.

METHODS

Two-year outcomes of patients from the prospective, multicenter ADAPT-DES study (N = 8,582) were analyzed according to HD status at enrollment. All patients underwent platelet function testing with the VerifyNow assay; HPR on clopidogrel was defined as P2Y12 reaction units (PRU) >208.

RESULTS

Compared with non-HD patients, patients on HD (n = 85) had significantly higher baseline PRU (median 254 vs. 188, p = .001) and more frequently had HPR (61.7% vs. 42.5%, p < .001). HD was associated with increased 2-year rates of MACE (death, myocardial infarction (MI) or definite stent thrombosis (ST); 23.4% vs. 10.7%, p < .001). HD was also strongly associated with 2-year overall mortality, cardiac death, MI, target vessel revascularization, major bleeding, stroke and ST. Following adjustment for HPR and other covariates, HD was independently associated with overall mortality, MI, ST, and major bleeding at 2 years. The relationship between HD status and 2-year MACE was consistent in patients with and without HPR (P_interaction = .78).

CONCLUSIONS

Nearly two-thirds of patients on HD exhibited HPR on clopidogrel, and both HD and HPR were independently associated with 2-year adverse outcomes after DES implantation. However, the deleterious impact of HD on clinical outcomes was present in both patients with and without HPR.

Application of virtual histological intravascular ultrasound in plaque composition assessment of saphenous vein graft diseases

OBJECTIVE

Saphenous vein grafts disease (SVGD) is a common complication after coronary artery bypass graft (CABG) and normally treated by percutaneous coronary intervention (PCI). The most common complication after SVG-PCI is slow or no-reflow. It is known that the no-reflow phenomenon occurs in up to 15% of the SVG-PCI and is associated with high risk of major adverse cardiac events (MACEs) and mortality, therefore, it is important to investigate the factors that could predict the clinical outcome of PCI for risk stratification and guiding interventions. In recent years, the spectral analysis of intravascular ultrasound (IVUS) radiofrequency data (virtual histology-IVUS [VH-IVUS]) has been used to provide quantitative assessment on both plaque compositions and morphologic characteristics.

DATA SOURCES

The PubMed, Embase, and Central databases were searched for possible relevant studies published from 1997 to 2018 using the following index keywords: "Coronary artery bypass grafting," "Saphenous venous graft disease," "Virtual histology-intravascular ultrasound," "Virtual histology-intravascular ultrasound," and "Percutaneous coronary intervention."

STUDY SELECTION

The primary references were Chinese and English articles including original studies and literature reviews, were identified and reviewed to summarize the advances in the application of VH-IVUS techniques in situ vascular and venous graft vascular lesions.

RESULTS

With different plaque components exhibiting a defined spectrum, VH-IVUS can classify atherosclerotic plaque into four types: fibrous tissue (FT), fibro fatty (FF), necrotic core (NC), and dense calcium (DC). The radiofrequency signal is mathematically transformed into a color-coded representation, including lipid, fibrous tissue, calcification, and necrotic core. Several studies have demonstrated the independent relationship between VH-IVUS-defined plaque classification or plaque composition and MACEs, but a significant association between plaque components and no-reflow after PCI in acute coronary syndrome. In recent years, VH-IVUS are applied to assess the plaque composition of SVGD, based on the similarity of pathophysiological mechanisms between coronary artery disease (CAD) and SVGD, further studies with the larger sample size, the long-term follow-up, multicenter clinical trials may be warranted to investigate the relationship between plaque composition of saphenous vein graft (SVG) by VH-IVUS and clinical outcomes in patients with SVGD undergoing PCI.

CONCLUSIONS

In degenerative SVG lesions, VH-IVUS found that plaque composition was associated with clinical features, future studies need to explore the relationship between VH-IVUS defined atherosclerotic plaque components and clinical outcomes in SVGD patients undergoing PCI, an innovative prediction tool of clinical outcomes can be created.

Contemporary Use of Embolic Protection Devices During Saphenous Vein Graft Intervention

BACKGROUND

Guidelines recommend use of embolic protection devices during percutaneous coronary intervention of saphenous vein grafts, but the use of these devices in contemporary practice is unclear. We thus sought to evaluate the patient characteristics and clinical outcomes associated with embolic protection device use during contemporary saphenous vein graft percutaneous coronary intervention.

METHODS AND RESULTS

We identified patients undergoing isolated saphenous vein graft percutaneous coronary intervention in the Veterans Affairs Healthcare System from January 2008 to June 2017. Patient and procedural characteristics associated with embolic protection device use were assessed, as well as unmeasured site variation. A propensity-matched cohort was constructed to compare outcomes at 30 days, including unsuccessful intervention, periprocedural myocardial infarction, and death. We identified 7266 vein graft interventions, and embolic protection was used in 37.9% of cases, with a significant decline over time ( P=0.001) that was most pronounced from 2014 to 2017 ( P<0.001). There was significant institutional variation in the use of embolic protection, with a 15.50 (95% credible interval, 9.21-29.71)-fold difference in odds of device use by changing facilities independent of patient or procedural factors. Use of embolic protection was associated with reduced risk of unsuccessful intervention (odds ratio, 0.27; 95% credible interval, 0.17-0.42) and 30-day mortality (odds ratio, 0.56; 95% credible interval, 0.36-0.87).

CONCLUSIONS

Use of embolic protection is decreasing with time and occurs in less than half of vein graft interventions. There is significant site variation in the use of embolic protection independent of patient characteristics, suggesting opportunities for the development of uniform practices to improve outcomes among those undergoing saphenous vein graft percutaneous coronary intervention.

New-generation drug eluting stent vs. bare metal stent in saphenous vein graft - 1 year outcomes by a propensity score ascertainment (SVG Baltic Registry)

BACKGROUND

Data regarding the efficacy of the percutaneous coronary intervention (PCI) with new-designed drug-eluting stent (new-DES) vs. bare metal stent (BMS) of saphenous vein grafts (SVG) stenosis is scarce. The primary objective was to compare one-year clinical outcomes of PCI in stenosis of SVG using new-DES vs. BMS in a real-world population.

METHODS AND RESULTS

We carried out a multi-center registry comparing new-DES with BMS in all consecutive patients undergoing PCI of SVG. The primary composite endpoint was major adverse cardiac and cerebrovascular events (MACCE) at 1 year. This observation included 792 consecutive patients (mean age 69 ± 8.9y), treated with either new-DES (n = 379, 47.9%) or BMS (n = 413, 52.1%). Among patients treated with new-DES compared with BMS, there was a lower risk of MACCE (21.4% vs. 28.3%, HR = 0.69, 95% CI 0.50-0.95, p = 0.025) as well as myocardial infarction (MI) (6.3% vs. 12.1%; HR 0.49, 95% CI 0.30-0.82, p = 0.005) at 1 year. After propensity score adjustment, the similar, significant reduction in MACCE and MI was observed in favor of new-DES (HR 0.66, 95% CI 0.46-0.96, p = 0.030; and HR 0.53, 95% CI 0.31-0.92, p = 0.020, respectively).

CONCLUSION

In patients undergoing PCI of SVG, the use of new-DES is associated with a reduced 1-year rate of MACCE and MI compared to BMS.

Intravascular Ultrasound Assessment of In-Stent Restenosis in Saphenous Vein Grafts

Outcomes after percutaneous coronary interventions (PCI) in saphenous vein grafts (SVG) are inferior compared with native coronary arteries, but the mechanisms of SVG in-stent restenosis (ISR) have not been well-described. Thus, we aimed to evaluate the patterns of SVG ISR using intravascular ultrasound (IVUS) in 54 SVG ISR lesions. Stent underexpansion was defined as minimum stent area (MSA) <5 mm². The time from stent implantation to presentation with ISR (9 BMS, 18 first-generation DES, and 27 second-generation DES) was 3.7 ± 3.0 years. IVUS-defined ISR patterns were categorized as mechanical (33%) or biological (67%). Mechanical patterns comprised 10 cases of stent underexpansion (MSA = 4.2 ± 0.9 mm²), 6 stent fractures or deformations, and 2 uncovered aorto-anastomotic lesions. Biological patterns comprised 19 cases of neoatherosclerosis, 13 excessive neointimal hyperplasia (NIH, 65 ± 11%), and 4 thrombi. Compared with biological patterns of ISR, mechanical patterns were more frequently located at the SVG anastomosis (72% vs 39%, p = 0.04) and at the SVG hinge motion site (55% vs 21%, p = 0.02). Although patients with mechanical patterns of ISR presented earlier than those with biological patterns (2.3 vs 4.4 years, p = 0.009), 61% of them were diagnosed >1 year after stent implantation. In conclusion, SVG ISR is dominated by biological patterns including neoatherosclerosis. Mechanical patterns of SVG ISR are associated with earlier presentation and location at graft anastomosis or hinge motion site.

Relationship between plaque composition by virtual histology intravascular ultrasound and clinical outcomes after percutaneous coronary intervention in saphenous vein graft disease patients: study protocol of a prospective cohort study

Background

Plaque composition and morphologic characteristics identified by virtual histology intravascular ultrasound (VH-IVUS) can determine plaques at increased risk of clinical events following percutaneous coronary intervention (PCI) among coronary artery disease (CAD) patients. However, there have been few studies to investigate the relationship between plaque composition of saphenous vein graft (SVG) by VH-IVUS and clinical outcomes in patients with saphenous vein graft disease (SVGD) undergoing PCI. The purpose of this study is to determine whether plaque components and characteristics by VH-IVUS can predict major adverse cardiac events (MACEs) among SVGD patients undergoing PCI.

Methods/design

This is a prospective cohort study conducted in Tianjin Chest Hospital, China. Participants with SVGD referred for PCI will be invited to participate in this study, and will be followed up at 1, 6, 12, 24 and 36 months post-PCI to assess clinical outcomes.

The planned sample size is 175 subjects. We will recruit subjects with SVGD scheduled to receive PCI, aged 18–80 years, with a history of previous coronary artery bypass graft (CABG) surgery more than 1 year ago, and willing to participate in the study and sign informed consent.

The composite primary study endpoint is the incidence of MACEs after PCI for SVGD, including death from cardiac causes, non-fatal myocardial infarction, unplanned target lesion revascularization (TLR) and target vessel revascularization (TVR). The primary outcome analysis will be presented as Kaplan-Meier estimates and the primary outcome analysis will be carried out using a Cox proportional hazards regression model.

Discussion

Once the predictive values of plaque components and characteristics by VH-IVUS on subsequent clinical outcomes are determined among SVGD patients undergoing PCI, an innovative prediction tool of clinical outcomes for SVGD patients undergoing PCI will be created, which may lead to the development of new methods of risk stratification and intervention guidance.

Trial registration

The study is registered to ClinicalTrials.gov (NCT03175952).

From debulking to delivery: sequential use of rotational atherectomy and Guidezilla™ for complex saphenous vein grafts intervention

Background

Percutaneous coronary interventions (PCI) of old calcified saphenous vein grafts (SVGs) is challenging and is associated with a considerably high risk of adverse ischemic events in the short- and long-term as compared to native coronary arteries. We report a case in which a non-dilatable, calcified SVG lesion is successfully treated with rotational atherectomy followed by PCI and stenting with local stent delivery (LSD) technique using the Guidezilla™ guide extension catheter (5-in-6 Fr) in the “child-in-mother” fashion.

Case presentation

A 70 years-old man with a dilated ischemic cardiomyopathy, triple coronary artery bypass grafting (CABG) in 1990 and chronic renal failure (baseline GFR: 45 ml/min/1.73 m²) underwent a coronary angiography for a Non-ST segment elevation myocardial infarction (NSTEMI). Native coronary circulation was completely occluded at the proximal segments. Grafts angiography showed a tandem calcified lesions of SVG on distal right coronary artery (RCA) and an ostial stenosis of the SVG on first obtuse marginal branch (OM1). Left internal mammary artery on the mid left anterior descending artery was patent. Ad Hoc PCI of SVG on RCA was attempted. The proximal calcified stenosis has been crossed with a 1.5 x 12 mm balloon only with the support of Guidezilla™, however the non-compliant (NC) balloon 2.5 x 15 mm was unable to break the hard and calcified plaque. After several attempts, the procedure was interrupted with a suboptimal result. An elective transradial PCI of SVG on RCA with rotational atherectomy was performed. Two runs with 1.25 mm burr and 2 runs with 1.5 mm burr were carried out. Then, the use of distal anchoring balloon warranted support and tracking, made as centring rail for the advance of the tip of the “mother-and-child” catheter into the SVG. During slow deflation of the balloon, the Guidezilla™ was advanced distal to the stenoses to be stented, thus allowing the placement of two long drug eluting stents according to a LSD technique.

Conclusions

Rotational atherectomy is a feasible option for non-dilatable stenoses in old SVGs when there is no evidence of thrombus or vessel dissection and the subsequent use of “mother-and-child” catheter has a key role, especially in case of radial approach, for long stents delivery.