PCI in Saphenous Vein Grafts
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief: Jason C. Choi, M.D., Xin Yang, M.D.
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Background
Coronary artery revascularization with saphenous veins (saphenous vein grafts or SVGs) has become a modern surgical standard for the treatment of coronary artery disease. This technique can be employed when a native coronary artery is blocked, thus causing a reduction or obstruction in blood flow. Cardiac surgeons use the sutured graft to connect the aorta to the coronary artery beyond the area of obstruction, so that blood flow may resume.
Despite their ability to restore blood flow, SVGs commonly encounter stenosis problems. The incidence of SVG stenosis is 15-30% one year after surgery, and it increases to 50% 10 years after surgery. Several factors contribute to stenosis of saphenous vein grafts, including intimal hyperplasia, plaque formation, and graft remodeling. Additionally, arterialization of the graft accelerates atherosclerosis. Furthermore, atheroma found in SVGs are more friable (easily break into small pieces) and more prone to thrombus than plaques found in native vessels. Another reason why SVGs are more susceptible to thrombotic occlusion is that they lack side branches.
Although intervention on a chronic total occlusion of an SVG may seem like an effective treatment strategy, it is best avoided.
Goals of Treatment
Primarily, the goal should be to detect and treat a SVG stenosis early in the development of ischemia while the SVG is still patent. As long as the SVG is not completely occluded, intervention can be performed.
Two additional overall goals of treating SVG stenosis include the resolution of symptomatic ischemia and the prevention/treatment of distal embolization.
Treatment Options
There are many different choices to consider when deciding the most appropriate treatment for SVG stenosis, including PTCA, PCI with bare metal or drug-eluting stents, PCI with covered stents, embolic protection devices, debulking/thrombus removal, and surgical revascularization.
Percutaneous Transluminal Coronary Angioplasty (PTCA)
PTCA has high initial revascularization success rates in the treatment of SVG stenosis. However, it is also associated with high rates of periprocedural complications, including acute vessel closure secondary to dissection and in-situ thrombosis. Additional complications include distal embolization and no reflow, which can lead to periprocedural infarction.
In modern interventional cardiology, PTCA is not often used as the sole means of treatment for SVG stenosis. Instead, stenting has become the cornerstone of treatment, while the use of PTCA has been limited to pre-dilation and post-dilation.
PCI with Bare Metal Stents (BMS) or Drug-eluting Stents (DES)
Most current vein graft treatment strategies employ stents (BMS or DES) as PCI with stenting is a superior treatment when compared to PTCA alone. The use of stents is associated with higher revascularization success rates, decreased restenosis rates, and improved clinical outcomes when compared to PTCA, as demonstrated in the Saphenous Vein De Novo (SAVED) Trial. [1] Generally, DES are preferred over BMS, since DES are associated with reduced rates of restenosis and target vessel revascularization when compared to BMS.