Rotational Atherectomy Before Stenting in the Body of a Saphenous Vein Graft

Paul Charbel

doi:10.11648/j.ijcts.20190501.11

Abstract

Management of stenosis of saphenous vein grafts in Coronary artery bypass graft (CABG) patients remains challenging despite the advance in interventional cardiology techniques. Rotational atherectomy is an adjunctive technique used in certain anatomical conditions in native coronary arteries; its use in saphenous vein graft is still contra-indicated by the manufacturer, and has only been reported in few cases in the literature. We report a case of a calcified, non-dilatable, distal saphenous vein graft to Circumflex lesion in a heart failure patient presenting with Non STEMI. The lesion was just proximal to the anastomosis and could not be crossed. Because of high surgical risk, and against manufacturer guidelines, rotational atherectomy of the lesion was performed and was successful with a very good angiographic result. Rotational atherectomy to facilitate percutaneous interventions in saphenous vein graft lesions is feasible, and could be attempted in experienced centers provided the absence of luminal thrombus or dissection.

Highlights

Management of stenotic lesions of saphenous vein grafts (SVG) remains challenging despite the major advances in revascularization techniques.SVG, which are used in almost every Coronary artery bypass graft (CABG) surgery, have a limited life expectancy as demonstrated in different studies: they have a patency rate at 10 years of 50-60%, while that of arterial conduits reaches 85-95%. [1]Percutaneous intervention (PCI) for CABG patients is currently a common procedure, accounting for 10-15% of all interventions in the majority of catheterization laboratories. [2] Cardiovascular events following PCI are doubled in case of a SVG lesion compared to a native coronary lesion [3]
[3] Since its first application in humans in 1988, rotational atherectomy has been used as an adjunctive therapeutic device to PCI, in case of calcified, difficult to dilate coronary artery lesions
Two major physical principles are the basis for the effectiveness of rotational atherectomy: first is differential cutting: the diamond-coated burr is capable of selectively ablating the inelastic plaque, pulverizing its content, while preserving the integrity of the elastic component which is the native vessel wall; the second principle is the orthogonal displacement of friction, by which, at high rotational speed, the device can be advanced and withdrawn without friction, through diseased and tortuous coronary arteries

Summary

Introduction

Management of stenotic lesions of saphenous vein grafts (SVG) remains challenging despite the major advances in revascularization techniques. [3] Because rotational atherectomy is most effective in fibrotic, inelastic lesions, and much less in soft, thrombus-containing stenoses, the manufacturer, (Boston Scientific), has restricted its indications to ostial, calcified, native vessel lesions, with specific anatomical characteristics; its use is contra-indicated in case of acute myocardial infarction, and in SVG lesions, where the risk of embolization of microparticles into the coronary microcirculation is high, with subsequent risk of no-reflow phenomenon and significant myocardial injury It is not recommended for use in patients with left ventricular ejection fraction (LVEF) less than 30% and in those at very high risk for coronary bypass grafting (CABG), for lack of scientific evidence [6]. The patient was treated with GPIIb/IIIa, Heparin, and Aspirin and Clopidogrel in preparation for PCI, which took place 48 hours later

Clinical Presentation

Procedure

Discussion

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Conclusion