Secondary Prevention, the Interventional Way

Abstract

The pathophysiology of accelerated atherosclerosis in saphenous vein grafts (SVG) relates to progressive atheroma burden, neointimal hyperplasia, and vascular remodeling.1,2 Unfortunately, the therapeutic and clinical consequences of SVG disease are not trivial, and interventional cardiologists are wary of performing percutaneous coronary interventions (PCI) on degenerated SVG. Intervening on flow-limiting stenoses in SVG has long been associated with high complication rates;3 what was not well known to this date was the risk of stenting non–flow-limiting disease in SVG.4 Although techniques to mitigate distal embolization during SVG intervention have proliferated in the past decade, even optimal intervention with embolic protection devices, including proximal protection devices, filters, aspiration tools, and covered stents, have attendant higher complication rates than does native vessel PCI.5 Drug-eluting stents (DES) are of benefit in reducing restenosis compared with bare metal stents in SVG, but clinical adverse events are only marginally reduced, if at all.6–8 Article see p 1978 In this context, one may be perplexed by the report of Rodes-Cabau et al4 in this issue of Circulation , which proposes stenting non–flow-limiting stenoses in SVG with paclitaxel-eluting stents. Their study was founded on reasonable scientific grounds. Emboldened by the findings in native coronary stenoses that DES deployment in nonobstructive lesions resulted in relatively low rates of major adverse cardiac events and restenosis9 and the rapid progression of disease in degenerated SVG, these investigators hypothesized that in patients referred for symptom-driven coronary angiography, …