Embolic Protection Devices in Saphenous Vein Graft Intervention: A Stitch in Time Saves Nine.

Abstract

Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) lesions is associated with a uniquely high risk of peri-procedural myocardial infarction (MI) and mortality-much greater than routine native coronary PCI. This is related to distal embolization which manifests as slow-flow and no-reflow phenomenon (SFNR) in 10% to 15% of SVG PCIs. Histopathology of SVG disease predisposes to its occurrence—the SVG plaques are large, soft, friable lipid-rich, containing large necrotic debris, cholesterol crystals and foam cells, lack calcification and fibrous caps, and are often associated with overlying thrombus. Fragmentation of the lipid-rich thrombotic plaque during PCI leads to distal embolization, platelet and leukocyte activation, release of vasospastic mediators (serotonin, endothelin), and activation of chemotactic mediators (tissue factor, thrombin/anti-thrombin III complex, and prothrombin fragments). The final result of plaque embolization is a triad of microvascular embolization, microvascular spasm, and microvascular thrombosis manifesting as SFNR.1 See Article by Paul et al Embolic protection devices (EPD) have been advocated in the AHA/ACC/SCAI PCI guidelines,2 when technically feasible, to reduce the risk of distal embolization during SVG PCI (Class I recommendation). This recommendation was based on the results of a single randomized controlled trial, the SAFER study, which showed significant reduction in major adverse cardiac events (MACE) with the use of a distal balloon occlusion device.3 In this issue of Circulation: Cardiovascular Interventions , Paul et al4 have attempted to evaluate the benefit of routine use of EPDs in SVG PCI. They performed a meta-analysis of 52 893 patients from 8 studies (6 registry/observational studies and 2 small randomized controlled trials) comparing all-cause mortality, MACE, MI (peri-procedural and late MI) and target vessel revascularization with and without use of EPDs. Because the National Cardiovascular Data Registry (NCDR) CathPCI Registry data included the largest number of patients among all the studies, a separate …