•Learning objectives :

• Aware of the risk-benefit of SVG

(Saphenous Vein Graft) intervention
• Prevention strategy of no-reflow
Saphenous Vein • Giving a perspective on utility of
Graft percutaneous SVG intervention in
both elective and acute setting
Intervention
 • Saphenous vein grafts (SVGs) are commonly used
during coronary artery bypass graft surgery (CABG)
for severe coronary artery disease.
• SVGs are prone to both degeneration and occlusion
due to its neointimal hyperplasia and accelerated
atherosclerosis process.
Introductio • Reports suggest rates of SVG failure in the first 12–
18 months may be as high as 25 %
n • Subsequent SVG interventions are plagued by
plaque embolization and no-reflow phenomenon
• Percutaneous Coronary Intervention (PCI) of SVGs
yields worse clinical outcomes compared with native
coronary artery PCI, but certain strategies may help
mitigate complications.
Pathophysiology
In general :
• Increased pressure load from vein graft arterialisation induces
neointimal growth and atherosclerosis development. 
• Occlusion within the first 12–18 months post-CABG
• Platelet aggregation, growth factor secretion, endothelial dysfunction,
inflammation, luminal foam cell accumulation, decreased local fibrinolytic
potential from plasminogen activator inhibitor-1 upregulation and marked
intimal hyperplasia.
• Occlusions after 12–18 months post-CABG
• following lipid deposition within intimal hyperplasia, eventually forming
atherosclerotic plaque.
• Deteriorating SVG lesions has thinner, more friable fibrous caps than
native coronary artery lesions, increases the incidence of plaque
embolization and platelet aggregation, especially during SVG
interventions.
• Atheroembolic debris liberated during SVG intervention becomes
lodged in distal capillaries, while the release of neurohormonal
factors such as serotonin can induce vasospasm.
 • Early (before hospital discharge)
(thrombosis)

Pathophysiological • Intermediate (1 month to 1

phases of SVGs year) (intimal hyperplasia)
Disease
• Late (beyond 1 year)
(atherosclerosis)
Early failure
• Within 30 days
• Acute vein graft thrombosis (60%)
• Focal stenoses at the proximal or
distal anastomotic sites
• Kinked grafts.
•Management :
• Urgent coronary angiography
• Emergency percutaneous
intervention if required.
Intermediate (1 month to 1 year)
• Within 1 to 12 months.
• Perianastomotic graft stenosis from
intimal hyperplasia.
• Mid SVG stenosis from fibrous
intimal hyperplasia.
•Management :
• Distal anastomotic sites have been
treated successfully with balloon
dilatation alone
• Stenting deployment compared to
balloon angioplasty may further
improve outcome.

• Recurrence of angina at about three months postoperatively

is highly suggestive of a distal graft anastomotic lesion and in
most cases, lead to evaluation for PCI
Late failure (>1 years after surgery)
• The most common cause of ischemia is the formation of new
• atherosclerotic plaques which contain
• foam cells,
• cholesterol crystals,
• blood elements,
• necrotic debris as in native vessels.
• However, these plaque have less fibrocollagenous tissue and calcification, so
they are softer, more friable, of larger size, and frequently associated with
thrombus.
Recommendations for PCI With Prior CABG

•Class I:
Patients with early ischemia (usually within 30 days) after CABG. (LOE: B)

•Class IIa:
1. Patients with ischemia occurring 1 to 3 years post-operatively and preserved
LV function with discrete lesions in graft conduits. (LOE : B)
2. Disabling angina secondary to new disease in a native coronary circulation.
(If angina is not typical, the objective evidence of ischemia should be
obtained). (LOE : B)
3. Patients with diseased vein grafts > 3 years following CABG. (LOE : B)
 Recommendations for PCI With Prior CABG

•Class III:
1. PCI to chronic total vein graft occlusions. (LOE : B)
2. Patients with multivessel disease, failure of multiple SVGs, and
impaired LV function. (LOE : B)

• Note:
The status of the LAD and its graft significantly influences the selection process.
(because lack of survival benefit of repeat surgery to treat non-LAD ischemia.)
• One year after C.A.B.G,
• patients begin to
develop new
atherosclerotic plaques Native
in the graft conduit
or Coronary
• show atherosclerotic
progression in the
Interventions
native coronary
arteries.
 • Treatment of protected left
main disease. Approaches to
• Recanalization of an old
total occlusion
native vessel
OR sites in post-
• native artery via venous or
arterial grafts.
bypass patients
 Intervention of The Aorto-ostial Lesion
• There is a question about need of prior debulking followed by stenting or
stenting alone of the aorto- ostial lesion.
• In a study by Ahmed et al. for both groups of patients with or without
prior debulking, the TLR rate after one year was similar at 19%.
• The technical concern during PCI of large and bulky aorto-ostial lesion
is the antegrade and retrograde embolization.
• There is distal protective device for antegrade embolization, but there
is none for retrograde embolization.
• 1-3yr after surgery, patients begin to develop
atherosclerotic plaques in the SVG.
• after 3 years, these plaques appear with Saphenous
increased frequency.
• At the early stage, dilation of the distal Vein Graft
anastomosis can be accomplished with little
morbidity and good long-term patency (80–
(SVG)
90%). Intervention
• Dilation of the proximal and mid-segment of the
vein graft was highly successful at 90%, with a s
low rate of mortality (1%), Q-wave MI, and
CABG(2%).
• The rate of non-Q-wave MI was 13%.
Intervention in degenerated saphenous vein grafts:
• The lesions that are bulky or associated with thrombus are considered to be
high-risk.
• The complications include distal embolization, no-reflow, abrupt closure,
and perforation.
• Different approaches were devised because there is much to lose from
the standpoint of distal embolization causing non-Q MI and increasing
long-term mortality.
• In the case of perforation of SVG, usually there is contained perforation
rather than cardiac tamponade due to the extrapericardial course of the
grafts.
 Rheolytic Thrombectomy
Dissolution and removal of clots from
coronary and peripheral arteries is
achieved by the creation of a flow-
mediated vacuum in the vicinity of the
treated lesion.

High speed injection of saline fluid

into an aspiration catheter forms a
low pressure zone at its orifice (the
Bernoulli effect).
• The pressure gradient between the
thrombus and the catheter tip draws clot
particles into the lumen of the device,
where they are further fragmented by the
high speed saline jets and then aspirated.

• The double lumen device allows both

saline injection and aspiration of
particulate matter into its collection
system.
  40%
In the VeGAS 2 trial, the Angiojet
device was compared with urokinase 30%
30.8%
33.1%

prior to percutaneous treatment of

Angiojet
Urokinase
20%
346 patients with thrombus-rich
lesions in native coronary arteries or 13.9% 15.0%
10%

SVG’s.
3.0%
1.7%
0%
Death MI MACE

20.0
% Angiojet
In this high risk population, Urokina
se
15.0
procedural success and hospital course %
13.6
without a major adverse cardiac event 10.0
% 11.8
%
were achieved with the Angiojet %

catheter in 86% of cases, significantly 5.0

%
more frequently than with urokinase 3.3
0.6%
3.3
%
(66%, P = 0.01) 0.0
%
%
Any
3.0%
Surgical Transfusion
Repair
 Aspiration
Thrombectomy
 The X-Sizer (EndicCOR
Medical, Inc.,) is a
thromboatherectomy
catheter of varying
dimensions.
 Rotation of a distal helical
cutter results in thrombus
maceration and extraction
into a distal vacuum
collection bottle.
 Experience in several
hundred pts has shown
this catheter to be effective
in debulking thrombus and
degenerating SVGlesions .
 The X-TRACT trial
 demonstrated that the
X- X Sizer Control
Sizer may be safely used 2
as an adjunct to PCI of 5
diseased SVGs and 2
thrombus-laden native 16. 170. 17.4
0 15.
9
coronary arteries. 1 8
 Less need for GP IIb/IIIa 5

Incidence
inhibitor bail-out in patients 1
treated with the X-Sizer, 0

(%)
suggesting a reduction in 5
periprocedural complications. 1. 0. 1. 1.
0 3 8 5
 MACE rates at 30 days were 0
similar in both groups Cardiac MI TVR MACE
Death
 There was a significantly lower
incidence of large
postprocedural MI at 30-day
follow-up among patients
treated with the X-Sizer device.
• In general, the X-Sizer system is
more effective in removing
thrombus and atheromatous
debris.
• While the AngioJet system was effective
only in the removal of fresh thrombus,
and not the friable, grumous vein graft
material or older organized thrombi
Prevention of distal embolisation
Distal protection devices.
Proximal protection devices.
 SAFER Trial – Comparison of
PercuSurge to Routine Stenting in SVG’s
801 Patients Randomized

20 30 Day MACE
16.5%

Reduced 42%
P<0.001
9.6%
%

0
Routine
PercuSurge
• The 800 patient multicenter
randomized SAFER trial
demonstrated a 50% reduction in in-
hospital adverse events with
PercuSurge distal protection during
SVG stenting, when compared to
stenting without protection
• Preliminary experiences with the
PercuSurge in AMI patients
undergoing percutaneous in AMI
patients undergoing percutaneous
 PercuSurge
System
Advantages Disadvantages
 Captures smaller  Transient occlusion
particles and
 Long “parking”
“humoral” mediators segment
 Frequently applicable  Side branches
unprotected
 Two operators
 Filter wire

.
• In Filter wire-type devices, An emboli
entrapment net is mounted on a 0.014"
guidewire and expanded distally to the
lesion.
• Intervention is then performed over the
guidewire.
• Filters do not block distal blood flow when
first deployed unlike occlusive devices.
• Dislodged material is caught by the distal
filter, which is then closed and retracted
only at the end of the procedure.
 Fire Trial: Randomized
BSC/EPI Filter vs. PercuSurge
inSVGPCI650 patients in 65 sites
FW GW
TIMI 3 Flow 95.7% 97.7%
Device Success 95.5% 97.2%
Death 0.9% 0.9%
MI 9.0% 10.0%
QMI 0.9% 0.6%
30 day MACE 9.9% 11.6%
Conclusion: FW not inferior to GW
Stone et al. J Am Coll Cardiol 2003; 41: 43A
 • These devices occlude flow into the vessel
using a balloon on the tip of or just the tip
of catheter
PROXIMAL • Two proximal occulusion catheters are in
OCCLUSIO use:
N DEVICES • Proxis catheter
• Kerberos embolic protection system
 Proxis In Vessel

• With inflow occlusion , retrograde

flow generated by distal collaterals
or infusion through a ”rinsing “
catheter can propel any liberated
debris back into the lumen of the
guiding catheter
• These have potential advantage of
providing embolic protection even
before the first wire crosses the
lesion.
Benefits to Proximal
Protection
 Nothing crosses the lesion prior to
protection
 Protection of main vessel and side
branches
 Captures large and small particles
 Can handle large embolic loads
Benefits to Proximal
Protection
• Nothing crosses the lesion prior
to protection
• Protection of main vessel and
side branches
• Captures large and small
particles
• Can handle large embolic loads
Is there a role for 2b3a
inhibitors in SVG
interventions ?
2B3A inhibitors offer NO
benefit in PCI of SVG’s
• Direct Stenting is the
technique of choice.
• Protection Device still
beneficial
Any Role for Vasodilator
in PCI of SVG’s?
Intracoronary
Vasodilator are
effective to :
Prevent no reflow
Treat no reflow
 New
Strategy
Small Stent for Large SVG’s
• Vein grafts are often oversized
• Stent size that matches the target native vessel provides adequate
flow
• Small stents in large saphenous veins decreases acute and longterm
MACE
• No increase in restenosis if MLA >6mm2
• Probably no need for protection device
Do drug eluting stents
offer and advantage in
SVG’s?
Advantage of DES vs BMS in large
SVG’s is not settled at this point
 Do covered stent offer
an advantage in SVG’s?
Existing Covered Stents
have not shown any
benefit for PCI of
SVG’s
Summary
Distal or proximal protection is effective
2b3A inhibitors offer no benefit
Pharmacological vasodilation is effective
Direct stenting is better
Small stent in large veins : A safe and provocative approach
Role of DES and Covered stents in SVG is not clear
Thank You