Tools & Techniques: Percutaneous intervention of saphenous vein graft lesions

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© Europa Digital & Publishing 2013. All rights reserved. Background The percutaneous treatment of patients with obstructive atherosclerotic disease in coronary saphenous vein bypass grafts (SVG) remains a challenge in interventional cardiology. Patients undergoing SVG intervention are often older, and suffer significant comorbidities. Moreover, SVGs usually present a degenerated pattern of atherosclerosis, with complex, friable, thrombotic-prone lesions. SVG interventions carry a higher risk of acute complications, mainly distal embolisation, and poorer long-term outcomes, mainly restenosis, than do native coronary vessel interventions1,2. The predictors of one-month major cardiac events after SVG intervention have been explored recently3. The degree of SVG degeneration assessed by the SVG degeneration score, the estimated plaque volume, angiographic evidence of thrombus, and increasing patient age are the correlates associated with the 30-day composite outcome of death, myocardial infarction (MI) and target lesion revascularisation (TLR). Thus, an important reason for poorer outcomes of percutaneous coronary interventions (PCI) in SVGs is the embolisation of atherothrombotic debris into the native coronary circulation, often resulting in periprocedural MI or reduced antegrade flow (“no-reflow”). Strategies for addressing this distal embolisation problem include both proximal and distal protection devices, as well as adjunctive pharmacology and stenting approaches. Embolic protection devices have demonstrated value in decreasing the risk of embolisation and post-procedural myocardial enzyme elevation after SVG intervention. While stenting has definitely been proved to be superior to balloon-only angioplasty for the treatment of SVG lesions, the choice of the type of stent (bare metal stent versus drugeluting stent) is still a matter of debate. Drug-eluting stents appear promising for the successful sealing of SVG disease; however, available long-term safety and effectiveness data are conflicting and give reason for caution.