Percutaneous coronary interventions on vein graft bifurcation lesions presenting as an acute coronary syndrome
Julien Feghaly1, Preetham Muskula2, Sundeep Kumar2
1Department of Internal Medicine, St. Louis University School of Medicine, St Louis, Missouri.
Insights
Interventions for graft bifurcation lesions in acute coronary syndromes (ACS) require tailored strategies. Customized approaches based on lesion characteristics and anatomy achieved excellent angiographic and clinical outcomes in three complex cases.
Area of Science:
- Cardiovascular Interventions
- Interventional Cardiology
- Vascular Surgery
Background:
- Graft bifurcation lesions, particularly in acute coronary syndromes (ACS), present unique interventional challenges.
- Optimal management strategies for these complex lesions are not well-defined.
Observation:
- Three distinct cases of complex graft bifurcation interventions are presented.
- Case 1 involved shared ostia of saphenous vein graft (SVG) and radial artery graft, necessitating a prioritized approach.
- Case 2 utilized a V stenting strategy with an embolization protection device (EPD) for a sequential jump graft.
- Case 3 employed a T stenting strategy for a highly angulated bifurcation involving SVG and a sequential graft.
Findings:
- Tailored interventional techniques, including provisional stenting, balloon angioplasty, V stenting, and T stenting, were successfully applied based on specific lesion characteristics.
- The chosen strategies led to excellent angiographic results in all three cases.
- All patients remained free of major adverse cardiovascular events at a 2-year follow-up.
Implications:
- Personalized interventional strategies can achieve favorable outcomes in complex graft bifurcation lesions, even in the context of ACS.
- These case examples highlight the adaptability of current interventional techniques to challenging anatomical scenarios.
- Further research into standardized approaches for graft bifurcation interventions may be warranted.
Abstract:
Interventions on graft bifurcation lesions are uncommon, especially in the setting of acute coronary syndromes (ACS). We described three cases of graft bifurcation intervention where we tailored our approach based on lesion characteristics, anatomy, and angulation to achieve excellent angiographic and clinical outcomes. In case 1, shared ostia of saphenous vein graft (SVG) to Diagonal (D) and Radial graft to Obtuse Marginal (OM) was severely stenosed. We prioritized the radial arterial graft as it is known to have a longer patency rate over a totally occluded SVG of an undetermined period. We performed provisional stenting of the ostium of the radial artery and balloon angioplasty of the SVG ostium, while stenting the body of the SVG. In case 2 (bifurcation lesion at the anastomosis of SVG to D1 and sequential jump graft to OM), we utilized a V stenting strategy after an embolization protection device (EPD) was deployed in the branch with a suitable landing zone. Kissing balloon dilatation of both the branches was performed both pre- and poststenting. In case 3 (bifurcation lesion at SVG to OM and Sequential "T" graft to diagonal), there was >90% angulation between both the grafts. We used "T" stenting strategy in this case. At 2-year follow-up, patients had no major adverse cardiovascular events since and remained symptom free.
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:29Venous Thrombosis III: Interprofessional Care
01:30Acute Coronary Syndrome I: Introduction
01:26Acute Coronary Syndrome V: Nursing Management
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations