Acute and long-term outcome of narrowed saphenous venous grafts treated by endoluminal stenting and directional atherectomy

Abstract

Angioplasty of the narrowed saphenous vein bypass grafts remains a difficult challenge. Over a 37-month period at this institution, 119 of 176 interventions (68%) on saphenous vein grafts (average age 8.3 years from bypass surgery to graft intervention) were performed using either directional coronary atherectomy (n = 35) or Palmaz-Schatz intracoronary stents (n = 84), representing 37% of all stents and 15% of all atherectomies during the study period, respectively. Of the 57 saphenous vein graft lesions treated with conventional balloon angioplasty during this period, 49 (86%) had 1 or more contraindications to stenting or directional atherectomy (thrombus, total occlusion, reference vessel <3 mm in diameter). The acute success rate was 99% for stents (1 failure to dilate) and 94% for directional atherectomy (2 failures to cross the lesion with the atherectomy device). Lumen diameter increased from 0.9 to 3.6 mm (reference vessel 3.6) for stents, and from 0.9 to 3.5 mm (reference 3.8) for atherectomy (for all comparisons, p = not significant), with no major complications (abrupt or subabrupt closure, emergent coronary bypass surgery, death, or Q-wave myocardial infarctions). During the same time period 50 of 57 vein grafts (88%) rejected for stenting or atherectomy were dilated successfully by conventional balloon angioplasty, with 3 patients (5%) requiring emergent coronary bypass surgery. Angiographic follow-up was available for 50 of 64 eligible patients (78%). Restenosis (defined as ≥50% stenosis at 6-month angiographic follow-up) was present in 13 of 50 lesions (26%, [95% confidence interval: 14%, 38%]), including 8 of 32 stented lesions (25%) and 5 of 18 atherectomy lesions (28%) (p = not significant). These data suggest that saphenous vein bypass graft stenoses may be treated safely and effectively using Palmaz-Schatz stenting or directional atherectomy, with short- and long-term results that may be better than those traditionally expected with conventional balloon angioplasty.