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Diffuse embolization following percutaneous transluminal coronary angioplasty of occluded vein grafts: the blush
J R Margolis1, L Mogensen, S Mehta
1Cardiovascular Laboratory, South Miami Hospital, Florida 33143.
Insights
The "blush phenomenon" after coronary angioplasty (PTCA) of occluded saphenous vein grafts may indicate embolic events, potentially leading to myocardial infarction. This finding suggests a need for modified PTCA approaches for graft occlusions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Saphenous vein grafts (SVGs) are commonly used for coronary artery bypass grafting.
- SVG failure, particularly occlusion, remains a significant clinical challenge.
- Percutaneous transluminal coronary angioplasty (PTCA) is a treatment option for SVG stenosis and occlusion.
Purpose of the Study:
- To investigate the significance of the
Main Methods:
- Retrospective analysis of 146 PTCA procedures on SVGs in 116 patients.
- Detailed observation of graft reperfusion, including myocardial staining duration.
- Correlation of the
Main Results:
- The
Conclusions:
- The
Abstract:
Percutaneous transluminal coronary angioplasty (PTCA) was performed on 146 saphenous vein grafts in 116 patients. In 29 patients, 31 grafts were totally occluded. Myocardial staining lasting over 5 minutes--"the blush phenomenon"--followed the opening of the occluded grafts in 9 of these patients. In 5 of these 9, enzyme release suggested infarction. A sixth patient died within a few hours of PTCA, with suspected infarction. Autopsy demonstrated diffuse and extensive distal coronary arterial embolization of grumous material, including cholesterol crystals, platelets, and fibrin. The blush phenomenon was not seen following PTCA in the remaining 20 patients with total occlusions, nor in any of the 87 patients with stenosed grafts. We have not observed the blush phenomenon following PTCA of more than 3300 coronary arteries. Of the 9 patients demonstrating the blush phenomenon, 6 had a recent history of myocardial infarction or unstable angina pectoris, compared with 4 of the remaining 20 patients with occluded grafts. We now approach occluded grafts with injection of intragraft thrombolytic agents or with atherectomy prior to PTCA. Future approaches may include atherectomy or laser angioplasty.