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Invasive Cardiology Board Review > Percutaneous Interventions inAortocoronary Saphenous VeinGraftsStephane Noble and Marc > Flashcards

Percutaneous Interventions inAortocoronary Saphenous VeinGraftsStephane Noble and Marc Flashcards

1
Q

Who implanted the first successful aortocoronary SVG?

A

Garrett and colleagues in May 1967

This procedure was later refined by René Favaloro.

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2
Q

What was the first conduit used as a coronary bypass graft in humans?

A

Internal Mammary Artery (IMA)

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3
Q

In what year did Arthur Vineberg implant the LIMA to improve myocardial blood supply?

A

1946

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4
Q

Who performed the first successful CABG and when?

A

R. Goetz and his team on May 2, 1960

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5
Q

What percentage of PCI in the United States is represented by PCI in vein grafts?

A

6%

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6
Q

What were the historical 10-year occlusion rates for SVG?

A

10% perioperative and 50% at 10 years

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7
Q

What is the overall 10-year SVG patency rate?

A

61%

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8
Q

What are the strongest long-term predictors of SVG graft patency?

A
  • Grafting into the LAD coronary artery
  • Grafting into a vessel that is at least 2.0 mm in diameter
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9
Q

What are the three distinct pathophysiologic processes observed in SVG disease?

A
  • Subacute thrombosis (within <1 month)
  • Neointimal hyperplasia (1 month to 1 year)
  • Vein graft atherosclerosis (clinically relevant >3 years)
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10
Q

True or False: Severe calcifications are common in SVG atherosclerosis.

A

False

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11
Q

What factors are associated with optimal graft flow at the end of surgery?

A
  • Large-diameter target vessels
  • Lack of significant native disease distal to the anastomosis
  • Several run-off branches
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12
Q

What is the primary cause of SVG failure years after surgery?

A

SVG atherosclerosis

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13
Q

What is the effect of sealing intermediate lesions with DES implantation?

A

Not associated with a significant reduction of cardiac events at 3-year follow-up

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14
Q

What is the preferred conduit for redo CABG according to ESC/EACTS guidelines?

A

Internal mammary grafts

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15
Q

What is neointimal hyperplasia?

A

Proliferation of smooth muscle cells and accumulation of extracellular matrix in the intimal compartment

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16
Q

What are the characteristics of SVG atherosclerosis compared to native coronary arteries?

A
  • Slower lipolysis
  • More active lipid synthesis
  • Higher lipid uptake
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17
Q

What diameter of the recipient artery is highly predictive of SVG patency?

A

> 2 mm

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18
Q

What is the relationship between cigarette smoking and vein graft outcomes?

A

Smoking is an important predictor of recurrent angina and poor long-term outcomes.

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19
Q

What is the effect of aspirin on vein graft patency?

A

Increases short- and midterm patency

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20
Q

What is the recommended alternative for patients who are aspirin intolerant after CABG?

A

Clopidogrel

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21
Q

What is the primary concern regarding suture line rupture?

A

Only in the early phase after surgery

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22
Q

What are the characteristic complications of PCI in degenerated SVG?

A
  • Distal embolization
  • No-reflow
  • Dissection
  • Abrupt closure
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23
Q

What is mechanical emboli protection?

A

Interposing a filter device or interrupting flow to prevent distal embolization

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24
Q

Fill in the blank: The combination of aspirin and clopidogrel is superior to aspirin alone for patients undergoing CABG for _______.

A

non–ST-segment elevation ACS

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25
Q

What is the purpose of using a distal balloon occlusive device in SVG PCI?

A

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.

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26
Q

Why should distal balloon occlusive devices not be used for aorto-ostial vein graft lesions?

A

A lack of antegrade flow during distal occlusion may lead to debris embolization into the ascending aorta and the brain

27
Q

What was the primary finding of the SAFER trial concerning emboli protection in SVG PCI?

A

The use of the distal balloon occlusion GuardWire device reduced periprocedural MI

28
Q

Which filter device was found to be noninferior to distal balloon occlusion in reducing periprocedural MI?

A

FilterWire

29
Q

What is a disadvantage of flow occlusive devices in SVG PCI?

A

They may induce ischemia and provide poor visualization of the lesion

30
Q

What were the outcomes at 30 days for proximal occlusion vs. distal protection in the PROXIMAL trial?

A

9.2% in the proximal protection group and 10% in the distal protection group (p = 0.0061 for noninferiority)

31
Q

True or False: The use of GP IIb/IIIa inhibitors in SVG interventions is considered useful.

A

False

32
Q

What ongoing study is assessing the efficacy of ticagrelor compared to clopidogrel in patients undergoing SVG PCI?

A

TiCAB study

33
Q

In a retrospective study, what was the trend observed when comparing bivalirudin with heparin in SVG PCI?

A

Fewer in-hospital non–Q-wave MI, repeat revascularization, overall vascular complications, and significantly fewer major CKMB increases

34
Q

What is the most common cause of recurrent ischemia early after surgical revascularization with SVG?

A

Acute SVG thrombosis

35
Q

What risk factors are associated with distal embolization during SVG PCI?

A
  • Angiographically visible thrombus
  • Intervention in ACS
  • Plaque ulceration
  • SVG degeneration
36
Q

What was the relative reduction in the primary endpoint of the SAFER trial using the GuardWire distal protection device?

A

42%

37
Q

What factors were found to predict 10-year SVG patency according to a study involving 1,074 patients?

A
  • Location of SVG anastomosis
  • Diameter of the recipient artery
38
Q

Fill in the blank: The presence of nonobstructive SVG lesions has been recently identified as a predictor of _______.

A

graft failure and cardiovascular events

39
Q

What is the recommended procedure for occluded SVGs?

A

Generally not recommended due to high risk of distal embolization with no-reflow phenomenon

40
Q

What are the observed mortality rates for redo CABG compared to the first surgery?

A
  • 3% for first surgery
  • 7% for redo CABG
41
Q

What is the significance of the SAFER and FIRE trials concerning SVG PCI with embolic protection?

A

Both showed a reduction in no-reflow and its clinical sequelae with the use of embolic protection devices

42
Q

True or False: Primary stenting without predilatation is preferred in SVG PCI.

A

True

43
Q

What were the findings of the RRISC trial regarding DES in SVG?

A

Reduced 6-month angiographic restenosis and TLR compared to BMS

44
Q

What was a surprising long-term outcome of DES in the RRISC trial?

A

Higher long-term mortality than BMS

45
Q

What did the ISAR-CABG trial find concerning the outcomes of DES vs. BMS?

A

No differences in terms of death, MI, or stent thrombosis

46
Q

What should be performed urgently when a sizable perioperative MI is suspected post-CABG?

A

Urgent coronary angiography

47
Q

What is the association between perioperative MI and subsequent health outcomes?

A

Increased risk of subsequent congestive heart failure and adverse outcomes

48
Q

What should be suspected in the presence of acute ST-segment elevation on ECG, rise of cardiac biomarkers, and hemodynamic instability?

A

Sudden graft occlusion

This is particularly relevant in the context of perioperative myocardial infarction (MI) and its associated risks.

49
Q

What is an alternative to redo surgery for acute graft occlusion?

A

Emergency PCI

This can involve treating the graft or approaching the native vessel supplied by the occluded graft.

50
Q

What factors should the heart team consider when choosing between percutaneous and surgical revascularization?

A

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.

51
Q

What was the preferred treatment in the presented case of ischemia secondary to diffuse spasm of the native coronary vessel?

A

Conservative treatment

This allowed for discontinuation of inotropic agents and introduction of vasodilators.

52
Q

True or False: SVG PCI is associated with better outcomes compared to interventions of the native circulation.

A

False

SVG PCI has been shown to have worse outcomes.

53
Q

What did the Symbiot trial conclude about covered stents compared to BMS?

A

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.

54
Q

What is the impact of DES on restenosis rates compared to BMS in SVG lesions?

A

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.

55
Q

What did the DELAYED RRISC study find regarding DES use in SVG lesions?

A

DES use was not associated with a reduction in repeat revascularization procedures, and higher mortality was observed

However, the study was small and underpowered.

56
Q

What did the first meta-analysis regarding DES and BMS in SVG PCI conclude?

A

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.

57
Q

What was the result of the RADIAL-CABG trial regarding transradial vs. transfemoral approaches?

A

Transradial access was associated with more contrast volume, longer procedure time, and higher crossover rate

However, it also resulted in greater patient satisfaction.

58
Q

What was the main finding of the SAFER trial regarding embolic protection devices?

A

There was a 42% relative reduction in the primary endpoint, mainly driven by a reduction in MI

The trial demonstrated clear cost-effectiveness.

59
Q

Fill in the blank: Early SVG failure may result from any process that contributes to _______.

A

flow reduction or thrombosis

This includes surgical issues and compromised outflow from distal CAD.

60
Q

What is the predictive diameter of the recipient artery for the 10-year patency rate of the corresponding vein graft?

A

> 2 mm

This measurement is significant for evaluating graft success.

61
Q

What was shown about glycoprotein IIb/IIIa inhibitors in SVG interventions?

A

They showed no benefit in SVG interventions

This finding was supported by randomized trials.

62
Q

What is the concept behind mechanical emboli protection in SVG PCI?

A

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.

63
Q

What does the efficacy summary table indicate about the use of stents in SVG interventions?

A

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.

Invasive Cardiology Board Review (42 decks)

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