87-Year-Old Female with Post-CABG Rest Angina

by | Nov 24, 2022 | CME INDIA Case Study | 0 comments

87-Year-Old Female with Post-CABG Rest Angina

CME INDIA Case Presentation by Dr. Ameet Sattur, DM Card, HCG-SUCHIRAYU hospital, Hubballi, Karnataka.



CME INDIA Case Study

A successful SVG graft PTCA with stenting was done at HCG-Suchirayu hospital, Hubballi.

An 87-year young !! female

  • Post -CABG status was admitted with Rest angina.
  • Coronary angiograph done revealed Triple vessel disease with SVG graft to RCA occluded and SVG graft to LAD having 95-99% tight stenosis (This was the graft that was keeping her alive).
  • Native vessel intervention was not possible due to dense calcification and chronic total occlusion.
  • After careful planning and preparation, the patient underwent successful PTCA with stenting to SVG graft with Distal Protection Spider Fx device with an excellent result.

Post Stenting result

Quick Take-Aways

  • One of the major challenges in the field of interventional cardiology is the treatment of saphenous vein graft (SVG) disease.
  • Saphenous venous graft -PCI (Percutaneous Coronary Intervention) remains a high-risk procedure with 5-to-20-fold higher risk of procedural complications compared with native coronary PCI.
  • The high-risk nature of SVG-PCI relates mainly to the degenerative nature of SVG disease, which is characterized by bulky, friable lesions dramatically increasing their embolic potential with subsequent higher risk of the no-reflow phenomenon and periprocedural myocardial infarction (MI).

CME INDIA Learning Points (Ref-1)

  • Saphenous vein grafts (SVGs) remain the most frequently used conduits in coronary artery bypass graft surgery (CABG).
  • Even today in 2022, despite advances in surgical techniques and pharmacotherapy, SVG failure rates remain high.
  • It often leads to repeat coronary revascularization.
  • The no-touch SVG harvesting technique (minimal graft manipulation with preservation of vasa vasorum and nerves) reduces the risk of SVG failure.
  • The effect of the off-pump technique on SVG patency remains unclear.
  • Perioperative aspirin and high-intensity statin administration are the cornerstones of secondary prevention after CABG.
  • Three pathophysiologic processes lead to SVG failure:
  • Thrombosis.
  • Technical failure is the predominant mechanism within the first week and during the first month after CABG.
  • Intimal hyperplasia- from 1 month to 1 year, and atherosclerosis beyond 1 year.
  • Treatment focuses on strict control of coronary artery disease risk factors.
  • Redo CABG is associated with higher perioperative mortality compared with percutaneous coronary intervention (PCI); hence, the latter is preferred for most patients requiring repeat revascularization after CABG.
  • SVG PCI is limited by high rates of no-reflow and a high incidence of restenosis during follow-up.
  • Drug-eluting and bare metal stents provide similar long-term outcomes in SVG PCI.
  • Despite all advances, 13% of patients who undergo CABG require repeat revascularization within 10 years, 18% of all percutaneous coronary interventions (PCIs) are performed in patients with previous CABG, and 6% of all PCIs are performed on SVGs, illustrating the frequent need for repeat revascularization after CABG. (2,3)
  • Update 2022
SVGs remain the most commonly used grafts during CABG.
Despite advances in surgical techniques and pharmacotherapy, SVG failure rates are high, often requiring subsequent interventions.
SVG PCI is challenging.
Periprocedural complications and restenosis remain higher compared with native coronary artery PCI, emphasizing the importance of prevention and favoring PCI of the corresponding native vessel if technically feasible.
Newer potent antiplatelet agents and lipid-lowering agents may delay the rapid progression of SVG atherosclerosis and reduce SVG failure rates.

CME INDIA Tail Piece

  • Dr. David C. Sabiston Jr., was the first physician to use a saphenous vein graft (SVG) to revascularize the right coronary artery in 1962 at Johns Hopkins University.
  • René Favaloro standardized the surgical technique of using SVGs for coronary artery bypass graft surgery (CABG), earning the title of “Father of CABG.”
  • More than 50 years later, and despite the limitations of SVGs, they remain the most frequently used conduits in conjunction with the left internal mammary artery (LIMA).

References:

  1. Saphenous Vein Graft Failure: From Pathophysiology to Prevention and Treatment StrategiesIosif Xenogiannis, Marco Zenati, Deepak L. Bhatt,et al.Circulation. 2021;144:728–745. 30 Aug 2021 https://doi.org/10.1161/CIRCULATIONAHA.120.052163
  2. Brilakis ES, O’Donnell CI, Penny W, et al. Percutaneous coronary intervention in native coronary arteries versus bypass grafts in patients with prior coronary artery bypass graft surgery: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.JACC Cardiovasc Interv. 2016; 9:884–893. doi: 10.1016/j.jcin.2016.01.034
  3. Brilakis ES, Rao SV, Banerjee S, Goldman S, et al.. Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass grafting patients: a report from the National Cardiovascular Data Registry.JACC Cardiovasc Interv. 2011; 4:844–850. doi: 10.1016/j.jcin.2011.03.018

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