Dr D. SOOKUR MBChB, MRCP (UK), MD (USA) … · Dr D. SOOKUR MBChB, MRCP (UK), MD (USA)...

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Dr D. SOOKUR

MBChB, MRCP (UK), MD (USA)‏

Interventional Cardiologist (Canada)

& Cardiac CT Specialist (USA)

Cardiac centre, Mauritius

EDUCATIONAL CONTENT ENDORSED BY EAPCI, A REGISTERED BRANCH

OF THE EUROPEAN SOCIETY OF CARDIOLOGY

Figure 1

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The PCR-EAPCI Textbook – Percutaneous interventional cardiovascular medicine

Saphenous vein graft disease Gabriel Maluenda, Pierfrancesco Agostoni, Pieter R. Stella, Paul Vermeersch, Itsik Ben-Dor, Lowell F.

Satler, Ron Waksman, Augusto D. Pichard

Background *Ischemic symptoms recur in 4-8% of patients/year following CABG. *Recurrence of symptoms can be attributed to progression of native vessel coronary disease (5%/year) and bypass conduit occlusion, particularly SVG failure (7% in week 1; 15-20% in first year; 1-2%/yr during the first 5-6 years, and 3-5%/yr in years 6-10 postop). *At 10 years postop, approximately half of all SVG conduits are occluded and only half of the remaining patent grafts are free of significant disease. 5-10% PCI case volume.

Alexander JH. JAMA 2005; 16;294(19):2446-2454

Widimsky P. Circulation 2004 30;110(22):3418-3423

Mauritian Context CABG in Mauritius for > 25 years

Aging saphenous vein grafts

1 % of PCI in Mauritius for SVG (v/s worldwide 10%)

Growing volume of PCI for SVG expected

More challenging

Specific graft lesion intervention subtypes and the related outcomes

Early ischaemia after CABG surgery (within the first 30 days) - early graft occlusion, usually thrombotic, occurs in up to 10% - 3% to 6% of patients develop clinically significant ischaemia - in symptomatic patients, 37% to 56% SVG are occluded on angiogram - PCI is recommended in the presence of clinical evidence of relevant ischaemia

Stenosis of the distal anastomosis - PCI has particularly good results, better than ostial and shaft location results

Chronic totally occluded SVG - related to poor short-term and long-term outcomes - native recanalisation is preferred if possible - PCI only justified in the presence of life-impaired symptoms or a large, jeopardised myocardium

Drug-eluting stents (DES) vs bare metal stents (BMS) to treat saphenous vein grafts

DES have shown to be more effective that BMS by reducing the rate of TLR

Initial concern about DES safety was raised by the long-term follow-up of a small-randomised trial

Long-term safety of DES is supported by a large amount of data coming from large real-world series

Strategies to prevent no-reflow in SVG interventions

Pharmacology - glycoprotein IIb/IIIa inhibitors increase the rate of bleeding without any apparent benefit - vasodalitors can improve angiographic results but do not appear to improve clinical outcomes

Covered stents - their use has been linked to worse outcomes in several randomised trials - use not recommended

Embolic protection devices - proven stategy that decreases periprocedural myocardial infarction and the no-reflow phenomenon - routine use is recommended in selected high-risk interventions - both proximal and distal protection devices should be available and used according to disease location in the graft itself

Direct and undersized stenting - alternative approach to prevent distal embolization

Acute myocardial infarction due to saphenous vein grafts

High related in-hospital mortality and poor long-term prognosis

Possible role of aspiration thrombectomy – especially in the presence of visible thrombus

Possible role of staged procedure after aggressive pharmacology approach