1018-49 Assessing a Strategy of Stand-alone Extraction Atherectomy Followed by Staged Stent Placement in Degenerated Saphenous Vein Graft Lesions

Abstract

Previously, we reported the high incidence of ischemic complications due to distal embolization (DE) following extraction atherectomy (TEC) of degenerated saphenous vein grafts (DSVG: grafts with lumen ectasia or irregularities comprising ≥50% of the graft length), frequently caused by adjunct PTCA (Group I). To assess whether a staged strategy (initial stand-alone TEC ± lyric therapy, followed by coumadin and stenting 1–2 months later) could reduce ischemic complications, we performed a pilot study in 28 pts with DSVG (Group II). Demographics and graft age (100 ± 47 vs. 99 ± 42 months) were similar, except for more recent MI in Group II (58.3% vs. 22.7%, P = 0.03). Group I (n = 44) Group II (n = 28) % DS (Pre/Final) 79 ± 14/30 ± 24 * 80 ± 17/45 ± 19 DE (%) 22.7 ** 10.7 Any In-hospital Complications 11.4% *** 0% Death/CABG/MI (%) 6.8/2.3/4.5 0/0/0 DS = diameter stenosis * p < 0.001 ** p = 0.20 *** p = 0.15 vs. Group II Among 27 pts in Group II eligible for follow-up (> 1 month), there were no major ischemic complications. There were 4 total occlusions [1 non-Q wave MI at 4 months and 3 silent occlusions at 6 weeks (1) and 2 months (2)]. 9 without clinical indication for additional therapy, 11 staged procedures with stenting (follow-up % DS = 56 ± 30%), and 3 without significant stenosis on follow-up angiography. We conclude that this staged angioplasty strategy in degenerated saphenous vein graft lesions: 1) may reduce distal embolization, but most importantly , avoids major in-hospital ischemic complications during the initial procedure: but 2) at the expense of ≈15% graft occlusions, which occurred more than 6 weeks after the initial procedure: and 3) prevented any deaths either during the initial procedure or during the follow-up period. These results underscore the importance of early (1 month) follow-up in all patients undergoing this staged TEC, followed by stent procedure in treating complex degenerated saphenous vein graft lesions.