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
- 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:
- 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).
- 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
- 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
- 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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