Vein Graft Angioplasty Research Articles

Effectiveness of the Arani double‐loop guiding catheters in angioplasty of aorto‐coronary vein grafts

Double-loop guiding catheters have been used for angioplasty of aorto-coronary vein grafts (VG) or grafted arteries through the VG in 31 cases. A catheter with a 90 degrees primary curve was usually the best choice for angioplasty of the VG to the right coronary artery (RCA). For angioplasty of the VG to the left coronary artery branches (LCA), a 90 degrees primary curve was used when the proximal segment of the VG was oriented horizontally and a 75 degrees (USCI, C.R. Bard, Inc., Billerica, MA) was used when the proximal segment was directed superiorly. Angioplasty of 32 lesions was attempted in 31 patients. These catheters provided good "back-up" in angioplasty of 30 lesions (94%). The lesions were crossed with balloon catheters in 29 cases (91%). There was one acute VG occlusion requiring coronary artery bypass graft (CABG) surgery, a complication not attributed to the guiding catheter. We conclude that Arani guiding catheters provide strong back-up, are helpful in angioplasty of the vein grafts, and could be used as the primary choice for VG angioplasties.

Saphenous vein graft angioplasty in a teenager

Percutaneous transluminal coronary angioplasty (PTCA) is a widely used technique for the elective and emergent revascularization of obstructive coronary artery disease. Due to the increasing frequency of atherosclerosis with age, PTCA has been practiced exclusively in an adult population. 1 Although the field of interventional pediatric cardiology has grown tremendously in recent years, 2 PTCA has not been reported in this age group. We recently performed PTCA in a teenager; to our knowledge this is the youngest patient reported to benefit from this evolving technique.

Percutaneous excimer laser angioplasty of aortocoronary saphenous vein grafts

Percutaneous coronary excimer laser angioplasty was successfully performed in two patients. An 85 year old woman with a 99% stenosis in a vein graft to a posterior descending artery had the stenosis reduced to 30% with laser angioplasty. Subsequent balloon angioplasty reduced the stenosis further to 20%. A second patient, a man aged 50 years, had multiple previous balloon angioplasties and stent implantation with two subsequent percutaneous atherectomies. Laser angioplasty of the vein graft to the obtuse marginal branch reduced the first of three sequential lesions from 60% to 40%, the second lesion from 90% to none and the third from 60% to 20% without the need for balloon angioplasty. Both procedures were well tolerated without chest pain, burning, vascular perforation or thrombus formation.These cases demonstrate the feasibility of safely performing percutaneous coronary excimer laser angioplasty. Additional studies are indicated to determine the clinical role and potential benefits of this procedure in relation to established procedures and other experimental devices.

Multiple myocardial infarctions associated with atheromatous emboli after PTCA of saphenous vein grafts. A clinicopathologic correlation.

Percutaneous transluminal coronary angioplasty (PTCA) of stenotic saphenous vein grafts is less invasive than repeat coronary bypass grafting; however, this procedure is complicated by atheromatous embolization in 2.5%-3.0% of cases, an incidence significantly higher than in angioplasty of native coronary vessels. We reviewed the cases of 98 patients who underwent elective saphenous vein graft angioplasty at our institution. Five patients (5.1%) had non-Q-wave myocardial infarctions after the procedure, documented by elevated serum creatine kinase. In four, atheroembolism was suspected during the procedure. Two patients died, and autopsy showed that both had multiple atherosclerotic emboli to the distal epicardial coronary artery supplied by the vein graft. In addition, multiple infarcts of varying age, some clearly antedating the angioplasty procedure, were identified. These findings suggest that both ongoing, recurrent atheroembolism as well as angioplasty-related embolism may occur in older vein grafts.

Role of angioplasty in patients with previous coronary artery bypass surgery

Fifty-nine patients with previous coronary artery bypass surgery (CABG) underwent coronary artery or vein graft angioplasty following a recurrence of symptoms, 141 lesions were attempted in 70 procedures. The overall angiographic success rate was 77%. Some angiographic success was achieved in 83% of patients. Complications included myocardial infarction in three (4.3%), death in one (1.4%), and iliac artery thrombosis in one (1.4%). No patients were referred for urgent surgery. Twenty-eight patients have undergone repeat coronary arteriography after 7.5 +/- 2.6 months (mean +/- SD), and 31% of lesions have recurred. Fifty-eight percent of patients without recurrence at follow-up continue to have improved symptoms. Treadmill exercise time was significantly prolonged in patients in whom all attempted lesions had been successfully dilated and in those in whom only some lesions were dilated. Our experience suggests that approximately 29% of patients with recurrence of angina following CABG may be suitable for angioplasty.

Percutaneous transluminal angioplasty in patients with prior myocardial revascularization surgery

Direct myocardial revascularization surgery using either the saphenous vein or internal mammary artery has become the definitive surgical treatment for coronary artery occlusive disease. Certain patients who have undergone these procedures, however, have recurrent myocardial ischemia due to progression of disease in unbypassed vessels, to obstruction in the arteries distal to the insertion of the bypass conduit, or to disease of the conduit itself. Balloon angioplasty may be used to relieve myocardial ischemia in these situations; however, initial studies suggested a low primary success rate coupled with excessive mortality and morbidity. Improvements in patient selection, equipment and technical expertise now allow angioplasty to be performed in this patient population with results comparable to that in the general coronary angioplasty population. Of the 3,016 angioplasty procedures performed between September 1980 and June 1987, 236 patients had previously undergone revascularization surgery. The primary success rate was 93% (390 of 419 stenoses successfully dilated). Overall, clinical restenosis was observed in 39%, including a 43% restenosis rate in patients undergoing only saphenous vein graft angioplasty. This did not differ appreciably from the restenosis rate in postbypass patients undergoing angioplasty of only native vessels (37%) or internal mammary arteries (42%). Emergency revascularization surgery was required in 7 of 236 patients (3%), each of whom had myocardial infarction. One of 236 patients (0.4%) died. Thus, angioplasty may be used to relieve recurrent myocardial ischemia in patients with prior direct myocardial revascularization procedures with a high initial success rate and acceptable risk. Early (less than 6 months) restenosis is not infrequent and remains the largest obstacle to a satisfactory clinical outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Current Status of Coronary Artery Bypass Grafting for Coronary Artery Atherosclerosis

Coronary artery bypass grafting has now undergone 18 years of proven benefit in the treatment of myocardial ischemic disease. The technique of CABG has been further extended to other situations in which myocardial blood supply is threatened, such as cardiac trauma, aneurysms of coronary arteries, and congenital lesions. The emphasis in choosing CABG over medical therapy in 1985 should be preservation of myocardium at jeopardy of infarction as well as relief of angina. Proximal stenoses in vessels subserving viable muscle that is ischemic at rest or with minimal exercise should be treated with reperfusion by angioplasty or CABG to prevent further injury. After infarction occurs and ventricular function is impaired, CABG is also necessary to preserve remaining myocardium at jeopardy. Such an aggressive approach seems warranted with today's excellent surgical results. Long-term results have also improved, as more attention has been paid to saphenous vein graft preparation, use of mammary artery grafts, complete revascularization, use of antiplatelet agents, control of spasm, and identification of hypercoagulable states that may require sodium warfarin (Coumadin). Angioplasty of vein grafts and distal anastomoses also appears promising to help extend the results of initial CABG. Figure 1 is our recommended approach for the treatment of coronary atherosclerosis.

Percutaneous Saphenous Vein Angioplasty to Avoid Reoperative Bypass Surgery

Thirty-seven patients with vein graft stenosis following coronary artery bypass underwent percutaneous transluminal vein graft angioplasty to avoid another operation. Location of the stenoses was at the aortic anastomosis in 3 patients, in the vein body in 12, and at the distal anastomosis in 22. All patients had disabling angina pectoris. Initial success (greater than 20% reduction of stenosis) was achieved in 35 patients. Vein graft angioplasty was performed within a year after bypass in 28 patients. The percent of stenosis and the pressure gradient across the obstruction were reduced from 84 to 24% and from 58 to 15 mm Hg, respectively. Complications of the procedure included emergency coronary artery bypass in 2 patients, myocardial infarction in 2, and ventricular fibrillation in 1. There were no deaths. Of 15 patients with stenosis at the aortic anastomosis or vein body, the dilation was initially successful in 14 but restenosis occurred in 7 within the first year after angioplasty. Only 2 of the remaining 7 were asymptomatic after vein graft angioplasty. However, for patients having vein graft angioplasty of the distal anastomosis, restenosis occurred in only 3, while 12 were asymptomatic at the end of the first year. The average hospital cost of a repeat coronary artery bypass operation was 2.8 times the cost of vein graft angioplasty.