Vein Graft Angioplasty Research Articles

Are all P2Y12 equally effective in vein graft angioplasty? A report from the UK database

Information of P2Y12 inhibitors in acute coronary syndromes with vein graft angioplasty is limited. This new analysis from the UK database was not able to find significant differences between Clopidogrel, Prasugrel and Ticagrelor. Large trials would be needed to reliably confirm the best antiplatelet regimen in this setting.

Reconstruction of long left anterior descending coronary artery successive lesions with left internal mammary artery and saphenous vein graft angioplasty: Early encouraging results

BackgroundDiffusely diseased LAD with long stenotic segment or multiple successive lesions in patients indicated for CABG are commonly encountered in our practice nowadays. This is a surgically challenging situation which needs extra-ordinary anastomotic surgical strategies. MethodsBetween May 2011 and April 2014, 37 CABG patients received long anastomotic patch on LAD. In 28 patients a long LIMA layout patch was used (Group I). In 9 patients (Group II), a long piece of reversed SVG was used to reconstruct LAD with LIMA finally anastomosed to SVG used for reconstruction. 30-day post-operative mortality, post-operative myocardial infarction, post-operative need for re-opening, post-operative need for IABC and 1 year post-operative freedom from MACCE were assessed. ResultsLIMA long layout patch was the standard level of care in these cases. We used SVG patch only when LIMA had short length, a very long anastomosis up to distal quarter of the LAD is needed, or small caliber delicate LIMA. In those cases we used SVG to reconstruct LAD then LIMA was anastomosed to the SVG patch. There was 1 re-opening for bleeding (2.7%). There was no post-operative MI. 1 case needed IABC (2.7%) for frequent ventricular extra-systoles that did not respond well to amiodarone, arrhythmia disappeared on 2nd post-operative day. There was no 30-day post-operative mortality. In 1 year follow-up for MAACE only 1 patient (2.7%) showed unstable angina for which coronary catheterization showed occluded SVG anastomosis to a large OM with a de novo lesion distally and PTCA with stenting of the native coronary was done successfully. ConclusionLAD reconstruction with both techniques showed satisfactory results in those surgically challenging cases. In most of cases we utilized long LIMA patch layout as standard level of care using SVG patch with superimposed LIMA anastomoses for technically selected cases.

Infrainguinal Vein Graft Stenoses: Long-Term Outcomes of Graft Angioplasty

Graft angioplasty combines the durability and ability of surgical bypasses to treat long arterial occlusions with the minimally invasive nature of endovascular procedures. The purpose of this study was to evaluate the efficacy of single and repeated graft angioplasty in revising failing infrainguinal vein bypass grafts and to determine predictors of medium- and long-term freedom from revision after graft angioplasty. This was a retrospective analysis from a prospectively maintained database. Consecutive endovascular revisions of graft-threatening lesions identified by duplex ultrasound surveillance were reviewed from 2003 to 2010. Patients were followed up until death, major amputation, or the end of follow-up, with the data last updated on January 1, 2013. 178 graft angioplasty procedures performed in 114 bypass grafts in 103 limbs from 98 patients were studied. At 5 years, freedom from revision was 22.6%, graft survival was 45.8%, amputation-free survival was 57.9%, and patient survival was 64.9%. Analysis of repeated angioplasties found no evidence that effectiveness diminishes significantly with the number of previous angioplasties performed (p=.892). Higher Rutherford Grade of ischemia and longer time interval from index surgery to first angioplasty were significant positive predictors of medium- and long-term patency. Percutaneous transluminal angioplasty of infrainguinal vein grafts is safe and effective in the treatment of failing grafts identified by duplex surveillance. Graft angioplasties do not lose effectiveness when repeated and have shown cumulative benefit in prolonging graft survival. Treatment of claudicants and time interval from graft implantation of more than 6monthsat the time of first angioplasty are positive predictors of at least medium-term patency after graft angioplasty.

Coronary Aneurysm Closure With Pericardial Covered Stent Evaluated With Optical Coherence Tomography

A 62-year-old man with personal history of arterial hypertension and smoking was admitted to our hospital with ST elevation myocardial infarction. Intravenous fibrinolytic therapy was given by emergency services during hospital transfer, which was effective. Routine coronary angiography showed moderate lesion on the proximal left anterior descending, proximal coronary aneurysm (Figure 1A, asterisk) and significant lesions at mid segment of circumflex (white arrow) and proximal segment of the second marginal (arrowhead). The case was discussed with the heart team and the decision was made to perform percutaneous coronary intervention. Balloon predilation was performed and drug-eluting stent was implanted in second marginal followed by direct drug-eluting stent implantation at mid segment of circumflex, fitting the proximal stent to distal origin of aneurysm. A 3.5 18 mm, pericardial, covered stent (Aneugraft, ITGI Medical Ltd., Israel) was implanted at circumflex aneurysm, overlapped to the distal drug-eluting stent with good final result (Figure 1B). Several optical coherence tomography pullbacks were conducted in order to confirm correct implantation of pericardial covered stent (Figure 2A, asterisk) and correct overlapping with distal drug-eluting stent (Figure 2B, white arrow). Patient was discharged on dual antiplatelet therapy with aspirin and clopidogrel for 1 year. Although initially designed for vein graft angioplasty, pericardial covered stents have been used to treat other problems in interventional cardiology, such as coronary aneurysm, with limited experience. We present here what is, to the best of our knowledge, the first case to use optical coherence tomography to evaluate the final result of pericardial covered stenting in coronary aneurysm. Figure 1. Figure 2.

Percutaneous bail-out treatment of vein graft rupture with a polytetrafluoroethylene-covered stent

Vessel perforation is an undesirable and life-threatening complication during vein graft angioplasty. We report on a case of vein graft rupture during angioplasty, which was successfully managed with deployment of a polytetrafluoroethylene-covered stent.

A prospective multicenter registry of laser therapy for degenerated saphenous vein graft stenosis: the COronary graft Results following Atherectomy with Laser (CORAL) trial

The primary aim of this study was to prospectively evaluate the safety and efficacy of Excimer laser atherectomy as a primary treatment strategy in consecutively eligible patients presenting for percutaneous coronary intervention (PCI) of degenerated saphenous vein graft (SVG) lesions using a multicenter registry. Prior single-center experience suggested that laser atherectomy may decrease acute procedural complications during treatment of degenerated SVGs, including lesions not amenable to distal protection devices (DPDs). The COronary graft Results following Atherectomy with Laser investigators enrolled 98 patients at 18 centers between June 23, 2003, and October 4, 2004, with greater than 50% stenosis of an SVG who presented for PCI due to angina pectoris or objective evidence of myocardial ischemia in a concordant myocardial distribution. Laser atherectomy was planned. Patients were excluded if the operator planned to utilize a DPD. Inclusion and exclusion criteria were aligned to those in the Saphenous vein graft Angioplasty Free of Emboli Randomized (SAFER) trial. The primary end point [30-day major adverse cardiac events (MACE)] occurred in 18/98 (18.4%) patients driven primarily by non-q-wave myocardial infarction. Major procedural complications included no reflow (n=5) and major dissection (n=1). No perforations occurred. Univariate predictors of 30-day MACE included lesion length, vessel angulation, plaque burden, SVG degeneracy score, number of laser pulses used, and larger-sized laser catheters. This study demonstrated that Excimer laser atherectomy of diseased SVGs is feasible with results comparable to the 30-day MACE in the control population from the SAFER trial. Whether the addition of laser to embolic protection devices is of any clinical utility remains to be tested in future studies.

Infected False Aneurysms of the Limbs Secondary to Chronic Intravenous Drug Abuse: Analysis of Perioperative Considerations and Operative Outcomes

To discuss the perioperative considerations and operative outcomes of 26 intravenous (i.v.) drug abusers who presented with infected false aneurysms of the limbs. The subjects were 20 men and 6 women with pseudoaneurysms (mean age 34 years, range 19-53 years). The femoral and brachial arteries were most commonly involved. All patients, except for those with active bleeding, underwent digital subtraction angiography or Doppler ultrasonography, or both. Treatment consisted of excision and ligation of the aneurysm and local debridement, followed by revascularization with a vein graft or vein patch angioplasty. The presenting symptoms and signs included a pulsatile mass (69%), ischemic pain (23%), active bleeding (38.5%), signs of inflammation (61.5%), and positive blood culture (31%). Bleeding complications developed in two patients, who underwent subsequent extra-anatomic bypass. One of these patients had hip disarticulation and eventually died. None of the remaining patients had claudication or required an amputation. The mean follow-up period was 24 months (range: 3-50 months). Only five (19.2%) patients received drug rehabilitation, whereas the remaining patients admitted to continued drug abuse after discharge from hospital. Limb salvage with immediate revascularization is safe and achieves functionality; therefore, its use is justified. Recidivism and continued abuse is the usual consequence after discharge from hospital, making recovery difficult.

Cutting Balloon Angioplasty Versus Standard Balloon Angioplasty for Failing Infra-inguinal Vein Grafts: Comparative Study of Short- and Mid-Term Primary Patency Rates

To evaluate the results of a recent change in practice in our institution using cutting balloon angioplasty instead of standard balloon angioplasty as the primary treatment for failing infra-inguinal vein bypass grafts. In this nonrandomized cohort study with a historical control, failing infra-inguinal vein grafts were identified at duplex surveillance or clinical examination. Patients had confirmatory arteriography and balloon angioplasty at the same attendance. Interventions proximal or distal to the graft itself and prosthetic grafts were not included. Patients were entered into a duplex graft surveillance program. Initial assessment of technical success was duplex or improvement 4-6 weeks after the primary angioplasty. Twenty-seven consecutive patients were treated with standard balloon angioplasty, then 11 consecutive patients were treated with cutting balloon angioplasty. Initial technical success was 74% for the standard balloon versus 82% for the cutting balloon. The primary patency rate at 6 months was 16/26 (62%) for standard balloon angioplasty and 8/10 (80%) for cutting balloon angioplasty (p = 0.44). The primary patency rate at 12 months was 9/25 (36%) for standard balloon angioplasty and 5/10 (50%) for cutting balloon angioplasty (p = 0.47). The use of cutting balloons for primary angioplasty of infra-inguinal vein grafts offers no definite advantage over standard balloon angioplasty in this institution or compared with patency rates after standard balloon angioplasty reported elsewhere. Larger multicenter studies would be required to demonstrate whether there was any real difference between the two techniques.

Technical modifications in endoscopic vein harvest techniques facilitate their use in lower extremity limb salvage procedures

We describe and report our results using endoscopic vein harvest (EVH) for lower extremity arterial bypass procedures, following the implementation of technical modifications specific to patients undergoing limb salvage procedures. We underwent training in EVH, followed by implementation of the technique in patients requiring limb salvage for lower extremity ischemia and aneurysms. After technical modifications in the technique were developed for limb salvage, we reviewed our experience in all patients who underwent minimally invasive distal bypass with EVH. Technical modifications include limited arterial dissection before vein harvest, the use of proximal and distal leg incisions for both exposure of arterial vessels and saphenous vein harvest, improved hemostasis techniques in the vein graft tunnel, avoidance of compression wraps to the ipsilateral harvest tunnel, complete removal of the vein with either reversed or nonreversed graft placement, and use of the endoscopic tunnel for conduit placement. Thirteen patients (14 limbs) have undergone minimally invasive distal bypass since technical modifications were implemented. Indications for EVH were rest pain (n = 12; 85.7%) and tissue loss (n = 8; 57.1%). Veins harvested were the ipsilateral great saphenous vein (n = 10; 71.4%), contralateral great saphenous vein (n = 2; 14.3%), and short saphenous vein (n = 2; 14.3%). No venous injuries occurred during endoscopic harvest, and all were used for bypass. Thirty-day primary and primary assisted patency rates were 85.7% and 92.9%, respectively. The limb salvage rate was 100%. Two patients developed postoperative hematomas, one early and one late, as a result of anticoagulation for cardiac comorbidities. Both patients required reoperation for successful re-establishment of patency. There were no perioperative deaths and no postoperative wound infections or complications. Two patients required a later prosthetic bypass, and two required a vein graft angioplasty. Complete wound healing was achieved in 75% of patients with preoperative tissue loss. Technical modifications in endoscopic saphenous vein harvest techniques facilitate their use in lower extremity limb salvage procedures. Vascular surgeons should become familiar with these techniques to minimize vein harvest wound complications and extend the options for limb salvage conduits, including use of both the ipsilateral and contralateral saphenous vein and the short saphenous vein. Meticulous hemostasis within the tunnel after endoscopic conduit harvest and avoidance of postoperative anticoagulation should help to prevent postoperative hematoma formation and early graft occlusion.

Use of Platelet Glycoprotein IIb/IIIa Inhibitors in Saphenous Vein Graft Percutaneous Coronary Intervention and Clinical Outcomes

Platelet glycoprotein (GP) IIb/IIIa inhibitors are widely used in percutaneous coronary intervention (PCI). Previous studies have suggested that they do not offer benefit in saphenous vein graft PCI. Nonetheless, their use remains widespread during vein graft angioplasty. We retrospectively analyzed 1,537 patients who underwent saphenous vein graft PCI. Patients who received a GP IIb/IIIa inhibitor (n = 941) were compared with those who did not receive any GP IIb/IIIa inhibitor (n = 596). The primary end point was myonecrosis after PCI (creatine kinase-MB level >3 times the upper reference limit). The incidence of myonecrosis after PCI was similar between the group that received GP IIb/IIIa and the group that did not (odds ratio for GP IIb/IIIa use 1.39, 95% confidence interval 0.97 to 2.00, p = 0.07). Propensity-adjusted analysis demonstrated no significant difference in myonecrosis after PCI, in-hospital mortality, Q-wave myocardial infarction, or bleeding (blood transfusion, retroperitoneal bleed, or hematoma) between the 2 groups. In an analysis restricted to patients who were treated with an emboli protection device, GP IIb/IIIa use was not associated with decreased myonecrosis after PCI (this was also the case for patients who were not treated with an emboli protection device). Unadjusted survival (mean follow-up 5.5 +/- 0.1 years) was similar between the group that received GP IIb/IIIa and the group that did not (log-rank test, p = 0.89). There was no difference in survival after adjusting for the propensity to receive a GP IIb/IIIa inhibitor (adjusted odds ratio for GP IIb/IIIa use 0.92, 95% confidence interval 0.69 to 1.23, p = 0.59). In conclusion, adjunctive use of platelet GP IIb/IIIa inhibitors in saphenous vein graft PCI does not appear to be associated with less myonecrosis or improved survival.

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Distal Protection Improved Reperfusion and Reduced Left Ventricular Dysfunction in Patients With Acute Myocardial Infarction Who Had Angioscopically Defined Ruptured Plaque

Distal protection, in the Saphenous Vein Graft Angioplasty Free of Emboli (SAFER) trial, is demonstrated to prevent distal embolism in the percutaneous coronary intervention of saphenous vein graft. However, in the Enhanced Myocardial Efficacy and Recovery by Aspiration of Liberated Debris (EMERALD) trial, it was not effective in the percutaneous coronary intervention of native coronary arteries in patients with acute myocardial infarction (AMI). We hypothesized that its effectiveness would be determined by lesion characteristics. Therefore, we classified the type of culprit lesion by angioscopy and examined its influence on the effectiveness of distal protection, comparing patients with AMI treated with and without distal protection. Consecutive patients with AMI treated without distal protection (n=110) from July 2000 to July 2002 and those treated with distal protection (n=81) from July 2002 to July 2004 were included. Patients in each group were subdivided according to whether or not they had angioscopically defined ruptured plaque at culprit lesion. Among those groups, incidence of no-reflow phenomenon, ST-segment resolution, myocardial blush grade, and left ventricular ejection fraction at 6 months were compared. Aspirated samples by distal protection were semiquantitatively and histologically analyzed and compared between patients with and without ruptured plaque. No-reflow phenomenon was most frequently (P<0.05) observed in patients with ruptured plaque treated without distal protection. ST-segment resolution (68+/-15% versus 40+/-21%, P<0.001), myocardial blush grade (2.6+/-0.5 versus 1.8+/-0.3, P<0.001), and left ventricular ejection fraction (47.2+/-6.7% versus 41.0+/-9.7%, P<0.01) were improved by distal protection among patients with ruptured plaque but not among patients without ruptured plaque. Aspirated samples >1 mm were detected more frequently (97.3% versus 78.5%, P<0.05) in patients with ruptured plaque than those without ruptured plaque. Histologically, aspirated samples contained plaque debris (95.3% versus 31.1%, P<0.05) more frequently in patients with ruptured plaque than in those without ruptured plaque. Distal protection reduced microcirculation damage and left ventricular dysfunction in patients with AMI who had angioscopically defined ruptured plaque. Distal embolization of plaque debris was detected more frequently in patients with ruptured plaque. These results suggest that microcirculation damage and left ventricular dysfunction are increased mainly by distal embolization of plaque debris rather than of thrombus.

Periprocedural Cardiac Enzyme Elevation Predicts Adverse Outcomes

Extensive clinical investigation throughout the 1990s validated periprocedural myonecrosis as a powerful predictor of adverse outcomes, so it is surprising that this remains a contentious point. Originally derided as “enzyme leaks” or “myocardial infarctlets,” periprocedural myocardial infarction (MI) has now been definitively linked in large data sets to long-term adverse outcomes, most notably mortality. It is not, however, always directly contributory or causative. For example, a large creatine kinase (CK) elevation caused by closure of a major side branch resulting in chest pain and development of new Q waves is obviously undesirable and causally related to the interventional procedure. Alternatively, even small, asymptomatic CK elevations have been clearly associated with worse long-term outcome, and although this may in part be causally related to the procedure, it is more likely that the relationship is caused by the underlying predisposing factors that led to the periprocedural MI, such as arterial inflammation predilecting to the occurrence of embolization or to a large degree of atheroma burden leading to more myonecrosis. Under these circumstances, it is likely that the heightened inflammatory state and the diffuse disease that is present are the real causative factors for worse long-term outcomes. Recently, aspirin resistance has been demonstrated to predict periprocedural myonecrosis. Thus, both through direct causation and also as an epiphenomenon, embolization and attendant periprocedural myonecrosis are associated with short, intermediate, and long-term adverse outcomes (Table 1). This review details this evolution in thought. View this table: TABLE 1. Mechanisms Behind Periprocedural Myonecrosis Periprocedural myonecrosis is a frequent occurrence in percutaneous coronary intervention (PCI). CK or CK myocardial band (CK-MB) elevation occurs in ≈25% of patients undergoing PCI. With the advent of sensitive troponin measurements, it is clear that at least 50% of patients undergoing PCI have postprocedural troponin elevation, reflecting the frequency with which embolization occurs. However, troponin offers …

Proximal protection during saphenous vein graft angioplasty: The Kerberos embolic protection system

Percutaneous intervention in the setting of aortocoronary saphenous vein graft disease is associated with a significant risk of distal embolization. Devices intended to minimize the clinical impact of embolization have primarily utilized distally placed occlusive balloons or filters. Although such systems are often effective, distal protection does have limitations. We report a novel proximal embolic protection and rinsing system intended to overcome some of these limitations.

Determinants of 30-day adverse events following saphenous vein graft intervention with and without a distal occlusion embolic protection device

Distal balloon occlusion was approved as a means of embolic protection during saphenous vein graft intervention based on its ability to decrease major adverse clinical events (MACEs) by 42% in the 801-patient Saphenous Vein Graft Angioplasty Free of Emboli Randomized (SAFER) trial. However, the cost and technical complexity of this device have limited its widespread use and prompted some to avoid its use in cases that appear at "low risk" for complications. If predictors of MACEs and their potential decrease by distal balloon occlusion could be identified, this would have important clinical implications in this challenging population. We therefore used standard demographic and angiographic variables and 2 new angiographic markers (extent of graft degeneration and estimated volume of plaque in the target lesion) to construct multivariable logistic regression models of 30-day of MACEs in the SAFER trial. Independent correlates of increased 30-day MACEs were more extensive vein graft degeneration (p = 0.0001) and bulkier lesions (larger estimated plaque volume, p = 0.0005). Use of a distal balloon occlusion device was independently predictive of lower 30-day rates of MACE (p = 0.01), with uniform benefit across risk strata (no significant interaction between device use and independent angiographic risk factors). Thus, the risk of 30-day MACEs after percutaneous intervention in aortocoronary saphenous vein grafts is increased in more diffusely diseased grafts and in bulkier lesions, but a significant benefit of the GuardWire was seen across all levels of MACE risk rather than just those perceived to be at highest risk.

Cost-effectiveness of distal embolic protection for patients undergoing percutaneous intervention of saphenous vein bypass graftsResults from the SAFER trial

The goal of this research was to determine the incremental cost and cost-effectiveness of embolic protection in patients undergoing percutaneous revascularization (PCI) of diseased saphenous vein bypass grafts (SVGs). Distal protection using the GuardWire balloon occlusion device has been shown to reduce major ischemic complications in patients undergoing SVG PCI, but the cost-effectiveness of this approach is unknown. We prospectively measured medical resource utilization and cost for 801 patients undergoing SVG intervention who were randomized to distal protection using the GuardWire (n = 406) or conventional treatment (n = 395) in the Saphenous Vein Graft Angioplasty Free of Emboli Randomized (SAFER) trial. Long-term survival and cost-effectiveness were projected based on observed 30-day outcomes and a validated survival model for postcoronary artery bypass graft patients. Compared with conventional treatment, distal protection increased initial procedural costs by ∼$1,600 ($6,326 vs. $4,779, p &lt; 0.001). However, by reducing ischemic complications, distal protection reduced mean length of stay by 0.4 days and other hospital costs by nearly $1,000 ($6,846 vs. $7,811, p = 0.018). As a result, overall initial hospital costs were only $582 per patient higher with distal protection. Based on the observed 30-day cost and outcome differences in the trial, the incremental cost-effectiveness ratio for distal protection was $3,718 per year of life saved and remained &lt;$40,000 per year of life saved in 97.3% of bootstrap simulations (95% confidence interval, $0 to $43,079). For patients undergoing PCI of diseased SVGs, distal protection using the GuardWire system is an attractive use of limited health care resources.

Cost-effectiveness of distal embolic protection for patients undergoing percutaneous intervention of saphenous vein bypass grafts: Results from the SAFER trial

The goal of this research was to determine the incremental cost and cost-effectiveness of embolic protection in patients undergoing percutaneous revascularization (PCI) of diseased saphenous vein bypass grafts (SVGs). Distal protection using the GuardWire balloon occlusion device has been shown to reduce major ischemic complications in patients undergoing SVG PCI, but the cost-effectiveness of this approach is unknown. We prospectively measured medical resource utilization and cost for 801 patients undergoing SVG intervention who were randomized to distal protection using the GuardWire (n = 406) or conventional treatment (n = 395) in the Saphenous Vein Graft Angioplasty Free of Emboli Randomized (SAFER) trial. Long-term survival and cost-effectiveness were projected based on observed 30-day outcomes and a validated survival model for postcoronary artery bypass graft patients. Compared with conventional treatment, distal protection increased initial procedural costs by approximately $1,600 ($6,326 vs. $4,779, p < 0.001). However, by reducing ischemic complications, distal protection reduced mean length of stay by 0.4 days and other hospital costs by nearly $1,000 ($6,846 vs. $7,811, p = 0.018). As a result, overall initial hospital costs were only $582 per patient higher with distal protection. Based on the observed 30-day cost and outcome differences in the trial, the incremental cost-effectiveness ratio for distal protection was $3,718 per year of life saved and remained <$40,000 per year of life saved in 97.3% of bootstrap simulations (95% confidence interval, $0 to $43,079). For patients undergoing PCI of diseased SVGs, distal protection using the GuardWire system is an attractive use of limited health care resources.

Percutaneous intervention of a bifurcating saphenous vein graft with simultaneous dual‐limb filter wire protection

Distal embolization during saphenous vein graft angioplasty may result in myocardial infarction. The use of dual nonocclusive filter wire during angioplasty in a bifurcating saphenous vein graft is described.

Procedural results and distal embolization after saphenous vein graft stenting and angioplasty for in-stent restenosis of grafts.

Saphenous vein graft (SVG) angioplasty is associated with frequent periprocedural complications due to distal embolization and a high risk of restenosis. The purpose of this single-center, retrospective study was to determine the distal embolization incidences and outcomes of stenting for SVG lesions and percutaneous angioplasty for in-stent restenosis of these SVGs. We studied 48 consecutive patients (mean age, 62 +/- 7 years, 92% men) who had prior CABG and underwent stent deployment to SVG lesions detected at our institution over a period of 4 years. Mean lesion length was 12.4 +/- 3.2 mm. The minimal lumen diameter increased from 0.7 +/- 0.3 mm to 3.2 +/- 0.4 mm after stenting. Distal embolization as no reflow/slow flow phenomenon occurred in 5 (10%) patients. Angiographic success was achieved in 98% of the patients. Procedural success was achieved in 96% of the patients. No reflow/slow flow phenomenon was observed, particularly in patients with acute coronary syndrome. During the follow-up, 11 patients (23%) had angiographic evidence of restenosis. Lesions were treated with balloon angioplasty and the minimal lumen diameter increased from 2.6 +/- 1.1 mm to 3.1 +/- 0.3 mm. The angiographic and procedural success rates were both 100%. There were no cases of "no" reflow/slow flow. Restenosis was particularly frequent in patients with diabetes mellitus, hypercholesterolemia, and acute coronary syndrome. Stent implantation in patients with de novo SVG lesions can be achieved with a high rate of angiographic and procedural success. The distal embolization risk is lower during angioplasty of in-stent restenosis lesions of SVGs compared to de novo SVG lesions.

Does the beneficial effect of distal protection in saphenous vein graft interventions vary with lesion length? A SAFER (Saphenous Vein Graft Angioplasty Free of Emboli Randomized) substudy

Background: The SAFER trial demonstrated a dramatic reduction in Major Adverse Clinical Events (MACE: a composite of death, Ml or revascularfzation) acutely and at 30 days following saphenous vein graft (SVG) percutaneous intervention (PCI) with the use of the Percusurge GuardWire TM distal protection device. This benefit was anributed to the prevention of distal migration of atherosclerotic debris with the device. Methods: We sought to evaluate if the reduction in MACE seen in the SAFER trial varied with the length of the treated lesion. We divided lesion lengths into quartiles and performed a stratified analysis to evaluate for effect modification by lesion length on the reduction in MACE with the GuardWireTM compared to patients treated with no distal protection. Rasutts: Of the 751 lesions treated, longer lesions were associated with a higher incidence of MACE in both the control group (p=O.Oll) and GuardWireTM group (p=O.OOl). As demonstrated in the table, use of the GuardWireTM was associated with a reduction in MACE in each quartile of lesion length. With multivariable modeling, shorter lesions showed a trend toward a greater relative reduction in MACE with use of the GuardWireTM (p=O.O97).