Directional coronary atherectomy for saphenous vein graft disease

Saphenous vein grafts (SVG) comprise a significant and increasing proportion of coronary interventional procedures at most centers. Directional coronary atherectomy (DCA) is well suited for treating focal SVG disease and is an effective therapy for lesions located in the ostium, shaft or body, and distal insertion site of saphenous vein grafts. Aorto-ostial SVG lesions may be technically difficult due to angulation and inability to fully engage the guide catheter, but success rates are relatively high and excellent angiographic results are usually achieved. Use of alternative guide catheters and stiffer guide wires can facilitate successful DCA of aorto-ostial lesions. DCA of SVG shaft segments or distal insertion sites are also associated with high success and low complication rates. Complex and thrombus-containing vein graft lesions are often well suited for DCA, and both patent and occluded grafts with extensive thrombus may also be effectively treated with DCA following selective intragraft thrombolysis. Technical aspects of vein graft DCA for these applications are reviewed.