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Percutaneous coronary intervention of totally occluded coronary venous bypass grafts: An exercise in futility?
Evan W Nardone1, Brandon M Madsen2, Melissa M McCarey3
1Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, United States.
Insights
Percutaneous coronary intervention (PCI) for totally occluded saphenous vein grafts (SVG) shows high procedural success. However, long-term outcomes remain poor, limiting clinical utility for this challenging PCI procedure.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Percutaneous coronary intervention (PCI) for diseased saphenous vein grafts (SVG) presents significant clinical challenges.
- Current guidelines recommend against PCI for chronically occluded SVG, despite improvements with modern techniques.
- Contemporary outcomes have improved with distal protection, vasodilators, drug-eluting stents, and prolonged dual antiplatelet therapy.
Purpose of the Study:
- To evaluate the procedural and long-term outcomes of PCI in totally occluded SVG using contemporary methods.
- To reassess the effectiveness of modern PCI techniques in managing occluded SVG.
Main Methods:
- Retrospective observational study of 35 patients undergoing PCI for totally occluded SVG.
- Minimum one-year dual antiplatelet therapy, with indefinite aspirin use.
- Assessment of major adverse cardiac events (MACE) including death, MI, stroke, repeat revascularization, or graft occlusion at a mean follow-up of 1221 days.
Main Results:
- High procedural success rate of 83% for PCI in totally occluded SVG.
- Significant intraprocedural complications (17%) including distal embolization or no-reflow.
- Poor long-term MACE-free survival: 30% at 3 years and 17% at 5 years.
Conclusions:
- PCI for totally occluded SVG is technically feasible with high procedural success.
- The clinical benefit of PCI for totally occluded SVG is limited by unfavorable long-term outcomes.
- Further research is needed to improve long-term results for SVG intervention.
Background:
Percutaneous coronary intervention (PCI) of diseased saphenous vein grafts (SVG) continues to pose a clinical challenge. Current PCI guidelines give a class III recommendation against performing PCI on chronically occluded SVG. However, contemporary outcomes after SVG intervention have incrementally improved with distal protection devices, intracoronary vasodilators, drug-eluting stents, and prolonged dual antiplatelet therapy.
Aim:
To reassess the procedural and long-term outcomes of PCI for totally occluded SVG with contemporary techniques.
Methods:
This was a retrospective observational study conducted at a single university hospital. The study population consisted of 35 consecutive patients undergoing PCI of totally occluded SVG. Post-procedure dual antiplatelet therapy was continued for a minimum of one year and aspirin was continued indefinitely. Clinical outcomes were assessed at a mean follow-up of 1221 ± 1038 d. The primary outcome was freedom from a major adverse cardiac event (MACE) defined as the occurrence of any of the following: death, myocardial infarction, stroke, repeat bypass surgery, repeat PCI, or graft reocclusion.
Results:
The study group included 29 men and 6 women with a mean age of 69 ± 12 years. Diabetes was present in 14 (40%) patients. All patients had Canadian Heart Classification class III or IV angina. Clinical presentation was an acute coronary syndrome in 34 (97%) patients. Mean SVG age was 12 ± 5 years. Estimated duration of occlusion was acute (< 24 h) in 34% of patients, subacute (> 24 h to 30 d) in 26%, and late (> 30 d) in 40%. PCI was initially successful in 29/35 SVG occlusions (83%). Total stent length was 52 ± 35 mm. Intraprocedural complications of distal embolization or no-reflow occurred in 6 (17%) patients. During longer term follow-up, MACE-free survival was only 30% at 3 years and 17% at 5 years.
Conclusion:
PCI of totally occluded SVG can be performed with a high procedural success rate. However, its clinical utility remains limited by poor follow-up outcomes.
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