saphenous venous graft interventions

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Text of saphenous venous graft interventions

  • 1. S.V.G. Interventions. DR GOPI KRISHNA

2. Svg pathology. Natural course. Problems in interventions. Techniques. Procedure related complications. Role of stents and supportive medications. 3. Patients who experience recurrence of ischemia after CABGlesions in saphenous vein graft (SVG). native arteries. internal mammary. Radial. gastroepiploic graft. proximal subclavian artery. 4. Early postoperative ischemia (3years after surgery): the most common cause of ischemia is the formation of newatherosclerotic plaques which contain foam cells, cholesterol crystals, blood elements, necrotic debris as in native vessels. However, these plaque have less fibrocollagenous tissue andcalcifi cation, so they are softer, more friable, of larger size,and frequently associated with thrombus. 7. The status of the LAD and its graft significantlyinfluences the selection process.( because lack ofsurvival benefit of repeat surgery to treat non-LADischemia.) 8. Interventions within hours of C.A.B.G: urgent coronary angiography may reveal acompromised graft. Once a graft is thrombosed-------opening ofthe native vessel is preferable. if the native vessel is not a reasonabletarget------------- balloon interventions(thrombectomy device) on the graft are alsoeffective if thrombus formation is notextensive. 9. ? Intracoronary thrombolytic therapy-1/3rdrequiring mediastinal drainage due tobleeding. 10. Native coronary interventions One year after C.A.B.G, patients begin to develop new atheroscleroticplaques in the graft conduits or show atherosclerotic progression in the nativecoronary arteries. 11. Approaches to native vessel sites in post-bypass patients Treatment of protected left main disease. recanalization of old total occlusion or native artery via venous or arterial grafts. 12. Intervention of the aorto-ostial lesion there is a question about need of prior debulkingfollowed by stenting or stenting alone of the aorto-ostial lesion. In a study by Ahmed et al. for both groups of patientswith or without prior debulking, the TLR rate after oneyear was similar at 19%. The technical concern during PCI of large and bulkyaorto-ostial lesion is the antegrade and retrogradeembolization. There is distal protective device for antegradeembolization but there is none for retrogradeembolization 13. Saphenous vein graft interventions 1-3yrafter surgery, patients begin to develop atheroscleroticplaques in the SVG. after 3 years, these plaques appear with increased frequency. At the early stage, dilation of the distal anastomosis can beaccomplished with little morbidity and good long-termpatency (8090%). Dilation of the proximal and mid-segment of the vein graftwas highly successful at 90%, with a low rate of mortality(1%), Q-wave MI, and CABG(2%). The rate of non-Q-wave MI was 13%. 14. Intervention in degeneratedsaphenous vein grafts: The lesions that are bulky or associated with thrombus areconsidered to be high-risk. The complications include distal embolization, no-refl ow,abrupt closure, and perforation. So different approaches were devised because there is muchto lose from the standpoint of distal embolization causingnon-Q MI and increasing long-term mortality. In the case of perforation of SVG, usually there is containedperforation rather than cardiac tamponade due to theextrapericardial course of the grafts and extensive post-pericardiotomy fi brosis 15. Rheolytic thrombectomy Dissolution and removal ofHypo tubeclots from coronary andperipheral arteries is achievedby the creation of a flow-mediated vacuum in theWatervicinity of the treated lesion. jetsExhaust lumen High speed injection of salinefluid into an aspiration catheterforms a low pressure zone atits orifice (the Bernoulli effect). 16. The pressure gradient between the thrombusand the catheter tip draws clot particles into thelumen of the device, where they are furtherfragmented by the high speed saline jets andthen aspirated. The double lumen device allows both salineinjection and aspiration of particulate matter intoits collection system. 17. In the VeGAS 2 trial, the 40%Angiojet device was compared30%33.1%with urokinase prior toAngiojet30.8%percutaneous treatment of 346 20% Urokinasepatients with thrombus-richlesions in native coronary13.9% 15.0%10%arteries or SVGs. 1.7% 3.0%0% Death MIMACE In this high risk population,20.0%Angiojetprocedural success andUrokinasehospital course without a major15.0%adverse cardiac event were13.6%achieved with the Angiojet 10.0%11.8%catheter in 86% of cases,significantly more frequently 5.0%than with urokinase (66%, P = 3.3%0.01) 0.0%3.3%0.6%3.0%Any Surgical Repair Transfusion 18. Aspiration thrombectomy The X-Sizer (EndicCORMedical, Inc.,) is athromboatherectomy catheterof varying dimensions. Rotation of a distal helicalcutter results in thrombusmaceration and extraction intoa distal vacuum collectionbottle. Experience in several hundredpts has shown this catheter tobe effective in debulkingthrombus and degeneratingSVG lesions . 19. The X-TRACT trialdemonstrated that the X- X-SIZERControlSizer may be safely used as an 25adjunct to PCI of diseasedSVGs and thrombus-laden20native coronary arteries.16.9 17.0 17.415.8 15Less need for GP IIb/IIIa Incidence (%)inhibitor bail-out in patients 10treated with the X-Sizer,suggesting a reduction inperiprocedural complications.51.0 0.3 1.8 1.5 MACE rates at 30 days were 0similar in both groupsCardiacMITVRMACE death There was a significantly lowerincidence of largepostprocedural MI at 30-dayfollow-up among patientstreated with the X-Sizer device. 20. In general, the X-Sizer system is moreeffective in removing thrombus andatheromatous debris . while the AngioJet system was effective onlyin the removal of fresh thrombus, and not thefriable, grumous vein graft material or olderorganized thrombi 21. ?Prevention of distal embolisation Distal protection devices. Proximaal protection devices. 22. SAFER Trial Comparison ofPercuSurge to Routine Stenting in SVGs 801 Patients Randomized 2030 Day MACE 16.5% Reduced 42%P


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