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[Rescue thrombectomy after stent implantation in a degenerating aortocoronary bypass]
M Brueck1, J Ludwig, H von Korn
1Medizinische Klinik II und Poliklinik, Friedrich-Alexander-Universität Erlangen-Nümberg. martinbrueck@t-online.de
Insights
Distal embolization during vein graft angioplasty can cause serious complications. The X-Sizer catheter effectively retrieved thrombotic debris, restoring blood flow and minimizing myocardial damage.
Area of Science:
- Cardiovascular Interventions
- Interventional Cardiology
- Vascular Surgery
Background:
- Percutaneous angioplasty of degenerated saphenous vein grafts carries a high risk of distal embolization.
- Atherosclerotic debris or thrombus showering can lead to critical complications during these procedures.
- The "no reflow" phenomenon is a significant concern in revascularization of narrowed aortocoronary grafts.
Observation:
- A 66-year-old male with coronary artery disease underwent angioplasty for critical stenoses in a left anterior descending vein graft.
- Following stent deployment, the patient experienced acute chest pain and ECG changes, indicating total occlusion.
- An X-Sizer catheter was used to aspirate thrombotic debris, significantly improving blood flow.
Findings:
- The X-Sizer catheter successfully retrieved embolic material from the occluded vein graft.
- Restoration of blood flow minimized myocardial tissue loss, indicated by a modest elevation in creatine kinase.
- The procedure demonstrated the catheter's efficacy in managing macroembolization events.
Implications:
- The X-Sizer catheter system offers a viable solution for managing distal embolization during vein graft angioplasty.
- This retrieval technique can prevent or mitigate myocardial damage in high-risk interventions.
- Compatibility with standard guiding catheters facilitates its integration into existing interventional workflows.
Background:
Distal showering of atherosclerotic debris or thrombus is a feared event during percutaneous angioplasty of degenerated vein grafts.
Case Report:
We report on a 66-year-old male patient with a history of coronary artery disease who was admitted into hospital with an acute coronary syndrome. He had had coronary artery bypass graft surgery in 1995. His chest pain resolved under treatment with aspirin, heparin, betablocker, and nitrate. A diagnostic angiogram demonstrated two critical stenoses of the left anterior descending graft. After a continuous infusion of tirofiban administered for 24 h prior to elective angioplasty, a JR 4SH 6 F guiding catheter (Cordis) was positioned. The lesions were crossed with a 0.014" Galeo F wire (Biotronik). A 4 mm x 16 mm stent graft (Jostent, Jomed) was deployed in the distal stenosis and a 4.5 mm x 32 mm self-expandable stent (Magic Wallstent, Boston Scientific) in the proximal stenosis. Thereafter, the patient suffered from chest pain, and the ECG showed ST elevation from V1 to V5. Angiography revealed total occlusion of the left anterior descending artery. An X-Sizer catheter (EndiCOR Medical, Inc.) was introduced and advanced through the vein graft with slow back-and-forth movements. After several aspirations, blood flow was significantly improved. A modest CK elevation (127 U/l) indicated a rather small loss of myocardial tissue.
Conclusion:
Percutaneous revascularization of narrowed aortocoronary saphenous vein grafts is associated with increased risk of distal embolization and "no reflow". The X-Sizer catheter system is compatible with commercially available guiding catheters, and capable of retrieving thrombotic debris after macroembolization from degenerated saphenous vein grafts including the native coronary artery.