Intervention in the occluded vein graft: with high risk can come great reward: review of techniques with case...

Total occlusion of a saphenous vein graft (SVG) can present as abrupt thrombotic occlusion in an atherosclerotic graft with resultant acute cardiac events or chronic total occlusion (CTO) with resultant angina symptoms. The risks of percutaneous coronary intervention (PCI) within an occluded graft include not only periprocedural myocardial infarction (MI), but also the risks that come part and parcel with any CTO intervention which include an increased probability of procedural failure, vessel perforation, dissection, high radiation, and contrast exposure, and the potential for worse outcomes. PCI of a chronically occluded graft remains a class III indication in current PCI guidelines because of the increased procedural risk and modest clinical data supporting improved outcomes. Acute-type occlusions, with bulky and thrombotic obstruction, while not specifically addressed in the guidelines, are also fraught with somewhat similar risks. In this review, we describe four case scenarios with occluded SVG and discuss challenges and techniques and available evidence that support these interventions.