Percutaneous Interventions inAortocoronary Saphenous VeinGraftsStephane Noble and Marc Flashcards
Who implanted the first successful aortocoronary SVG?
Garrett and colleagues in May 1967
This procedure was later refined by René Favaloro.
What was the first conduit used as a coronary bypass graft in humans?
Internal Mammary Artery (IMA)
In what year did Arthur Vineberg implant the LIMA to improve myocardial blood supply?
1946
Who performed the first successful CABG and when?
R. Goetz and his team on May 2, 1960
What percentage of PCI in the United States is represented by PCI in vein grafts?
6%
What were the historical 10-year occlusion rates for SVG?
10% perioperative and 50% at 10 years
What is the overall 10-year SVG patency rate?
61%
What are the strongest long-term predictors of SVG graft patency?
- Grafting into the LAD coronary artery
- Grafting into a vessel that is at least 2.0 mm in diameter
What are the three distinct pathophysiologic processes observed in SVG disease?
- Subacute thrombosis (within <1 month)
- Neointimal hyperplasia (1 month to 1 year)
- Vein graft atherosclerosis (clinically relevant >3 years)
True or False: Severe calcifications are common in SVG atherosclerosis.
False
What factors are associated with optimal graft flow at the end of surgery?
- Large-diameter target vessels
- Lack of significant native disease distal to the anastomosis
- Several run-off branches
What is the primary cause of SVG failure years after surgery?
SVG atherosclerosis
What is the effect of sealing intermediate lesions with DES implantation?
Not associated with a significant reduction of cardiac events at 3-year follow-up
What is the preferred conduit for redo CABG according to ESC/EACTS guidelines?
Internal mammary grafts
What is neointimal hyperplasia?
Proliferation of smooth muscle cells and accumulation of extracellular matrix in the intimal compartment
What are the characteristics of SVG atherosclerosis compared to native coronary arteries?
- Slower lipolysis
- More active lipid synthesis
- Higher lipid uptake
What diameter of the recipient artery is highly predictive of SVG patency?
> 2 mm
What is the relationship between cigarette smoking and vein graft outcomes?
Smoking is an important predictor of recurrent angina and poor long-term outcomes.
What is the effect of aspirin on vein graft patency?
Increases short- and midterm patency
What is the recommended alternative for patients who are aspirin intolerant after CABG?
Clopidogrel
What is the primary concern regarding suture line rupture?
Only in the early phase after surgery
What are the characteristic complications of PCI in degenerated SVG?
- Distal embolization
- No-reflow
- Dissection
- Abrupt closure
What is mechanical emboli protection?
Interposing a filter device or interrupting flow to prevent distal embolization
Fill in the blank: The combination of aspirin and clopidogrel is superior to aspirin alone for patients undergoing CABG for _______.
non–ST-segment elevation ACS
What is the purpose of using a distal balloon occlusive device in SVG PCI?
To stop antegrade flow and aspirate the blood column within the vein graft before restoring antegrade flow
This method helps in preventing embolization during the procedure.
Why should distal balloon occlusive devices not be used for aorto-ostial vein graft lesions?
A lack of antegrade flow during distal occlusion may lead to debris embolization into the ascending aorta and the brain
What was the primary finding of the SAFER trial concerning emboli protection in SVG PCI?
The use of the distal balloon occlusion GuardWire device reduced periprocedural MI
Which filter device was found to be noninferior to distal balloon occlusion in reducing periprocedural MI?
FilterWire
What is a disadvantage of flow occlusive devices in SVG PCI?
They may induce ischemia and provide poor visualization of the lesion
What were the outcomes at 30 days for proximal occlusion vs. distal protection in the PROXIMAL trial?
9.2% in the proximal protection group and 10% in the distal protection group (p = 0.0061 for noninferiority)
True or False: The use of GP IIb/IIIa inhibitors in SVG interventions is considered useful.
False
What ongoing study is assessing the efficacy of ticagrelor compared to clopidogrel in patients undergoing SVG PCI?
TiCAB study
In a retrospective study, what was the trend observed when comparing bivalirudin with heparin in SVG PCI?
Fewer in-hospital non–Q-wave MI, repeat revascularization, overall vascular complications, and significantly fewer major CKMB increases
What is the most common cause of recurrent ischemia early after surgical revascularization with SVG?
Acute SVG thrombosis
What risk factors are associated with distal embolization during SVG PCI?
- Angiographically visible thrombus
- Intervention in ACS
- Plaque ulceration
- SVG degeneration
What was the relative reduction in the primary endpoint of the SAFER trial using the GuardWire distal protection device?
42%
What factors were found to predict 10-year SVG patency according to a study involving 1,074 patients?
- Location of SVG anastomosis
- Diameter of the recipient artery
Fill in the blank: The presence of nonobstructive SVG lesions has been recently identified as a predictor of _______.
graft failure and cardiovascular events
What is the recommended procedure for occluded SVGs?
Generally not recommended due to high risk of distal embolization with no-reflow phenomenon
What are the observed mortality rates for redo CABG compared to the first surgery?
- 3% for first surgery
- 7% for redo CABG
What is the significance of the SAFER and FIRE trials concerning SVG PCI with embolic protection?
Both showed a reduction in no-reflow and its clinical sequelae with the use of embolic protection devices
True or False: Primary stenting without predilatation is preferred in SVG PCI.
True
What were the findings of the RRISC trial regarding DES in SVG?
Reduced 6-month angiographic restenosis and TLR compared to BMS
What was a surprising long-term outcome of DES in the RRISC trial?
Higher long-term mortality than BMS
What did the ISAR-CABG trial find concerning the outcomes of DES vs. BMS?
No differences in terms of death, MI, or stent thrombosis
What should be performed urgently when a sizable perioperative MI is suspected post-CABG?
Urgent coronary angiography
What is the association between perioperative MI and subsequent health outcomes?
Increased risk of subsequent congestive heart failure and adverse outcomes
What should be suspected in the presence of acute ST-segment elevation on ECG, rise of cardiac biomarkers, and hemodynamic instability?
Sudden graft occlusion
This is particularly relevant in the context of perioperative myocardial infarction (MI) and its associated risks.
What is an alternative to redo surgery for acute graft occlusion?
Emergency PCI
This can involve treating the graft or approaching the native vessel supplied by the occluded graft.
What factors should the heart team consider when choosing between percutaneous and surgical revascularization?
The nature of the graft dysfunction, the territory affected, and the patency status of the corresponding native vessel
These considerations are crucial for optimal patient outcomes.
What was the preferred treatment in the presented case of ischemia secondary to diffuse spasm of the native coronary vessel?
Conservative treatment
This allowed for discontinuation of inotropic agents and introduction of vasodilators.
True or False: SVG PCI is associated with better outcomes compared to interventions of the native circulation.
False
SVG PCI has been shown to have worse outcomes.
What did the Symbiot trial conclude about covered stents compared to BMS?
Covered stents have a higher binary in-stent restenosis rate than BMS with no difference in MACE
This suggests that covered stents do not provide the expected benefits in preventing complications.
What is the impact of DES on restenosis rates compared to BMS in SVG lesions?
DES is associated with significantly lower restenosis rates after adjustment for baseline characteristics
Restenosis rates were 12.5% and 22.0% for BMS compared to 7.5% and 20% for DES at 1 and 3 years, respectively.
What did the DELAYED RRISC study find regarding DES use in SVG lesions?
DES use was not associated with a reduction in repeat revascularization procedures, and higher mortality was observed
However, the study was small and underpowered.
What did the first meta-analysis regarding DES and BMS in SVG PCI conclude?
DES use was associated with improved TLR and TVR rates without increased mortality
This meta-analysis included 25 studies and a total of 5,755 patients.
What was the result of the RADIAL-CABG trial regarding transradial vs. transfemoral approaches?
Transradial access was associated with more contrast volume, longer procedure time, and higher crossover rate
However, it also resulted in greater patient satisfaction.
What was the main finding of the SAFER trial regarding embolic protection devices?
There was a 42% relative reduction in the primary endpoint, mainly driven by a reduction in MI
The trial demonstrated clear cost-effectiveness.
Fill in the blank: Early SVG failure may result from any process that contributes to _______.
flow reduction or thrombosis
This includes surgical issues and compromised outflow from distal CAD.
What is the predictive diameter of the recipient artery for the 10-year patency rate of the corresponding vein graft?
> 2 mm
This measurement is significant for evaluating graft success.
What was shown about glycoprotein IIb/IIIa inhibitors in SVG interventions?
They showed no benefit in SVG interventions
This finding was supported by randomized trials.
What is the concept behind mechanical emboli protection in SVG PCI?
Interposing a device between the treated lesion and distal vasculature to prevent distal embolization
This approach has led to significant reductions in 30-day MACE.
What does the efficacy summary table indicate about the use of stents in SVG interventions?
Majority of SVG PCIs performed are stent-based, and covered stents and DES have shown improved outcomes compared to BMS
However, GP IIb/IIIa inhibitors are not recommended.
