Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures—Part I

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effects on the site of obstruction has been termed “remodeling.” Part I of this six-part series focuses on mechanisms of remodeling after various interventional techniques, particularly balloon angioplasty.     

Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures—Part IV

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effects on the site of obstruction has been termed “remodeling.” Part IV of this six-part series focuses on morphologic correlates of coronary angiographic patterns of remodeling after balloon angioplasty and discusses effects of angioplasty on adjacent, nondilated vessels.     

Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures—Part II

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effects on the site of obstruction has been termed “remodeling.” Part II of this six-part series focuses on morphologic causes of acute closure after remodeling and discusses findings late after successful balloon angioplasty remodeling.     

Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures-Part III

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effects on the site of obstruction has been termed “remodeling.” Part III of this six-part series focuses on intimal proliferation and chronic recoil in patients undergoing previous remodeling techniques by balloon angioplasty.     

Preoperative balloon dilatation of obstructed total anomalous pulmonary venous connection in a neonate.

Prompt recognition and early surgical correction are mandatory in neonates presenting with obstructed total anomalous pulmonary venous connection (TAPVC). Preoperative balloon angioplasty of obstructed TAPVC in a sick neonate is rarely reported. We describe successful short-term palliation with balloon angioplasty of a critically ill neonate with obstructed supracardiac TAPVC.     

Influence of expanded balloon diameter on palmaz-schatz stent recoil

After successful stent implantation, the residual luminal diameter of the stented vessel is usually smaller than the maximal stent-expanded balloon diameter. The goal of this study was to determine whether immediate vessel diameter recoil after Palmaz-Schatz stenting is affected by the final expanding balloon diameter used during stent deployment. Single Palmaz-Schatz balloon expandable stents were successfully placed in 108 stenotic lesions. There were 68 patients with 75 saphenous vein graft (SVG) and 30 patients with 33 native coronary artery lesions, including 26 restenotic and 82 de novo occlusive (>50% diameter stenosis) lesions. Quantitative coronary angiography was used for the assessment of stent recoil, defined as the difference between the minimal diameter of the fully expanded balloon and the postprocedure minimal lumen diameter divided by minimal diameter of the fully expanded balloon. A strong correlation (r = 0.94) was found between the minimal diameter of the fully expanded balloon and poststenting minimal lumen diameter. Immediate recoil was 11.3 ± 7.5%, responsible on an average for 0.4 ± 0.2-mm acute lumen loss. Recoil was less in SVG than in coronary arteries (9.7 ± 6.6% vs. 14.0 ± 7.8%; P = 0.004, and 0.3 ± 0.2 vs. 0.4 ± 0.2 mm; p = 0.01). Lesions were divided into four subgroups, based on the final stent expanding balloon diameter: (1) ?3.0 mm (n = 33); (2) >3 ± 3.5 mm (n = 43); (3) >3.5 ± 4 mm (n = 23); and (4) >4 mm (n = 9). For the four subgroups, the percentage recoil values were 15.0 ± 5.7, 10.4 ± 8.2, 9.0 ± 5.4, and 4.7 ± 2.0, respectively (P <0.001). Mean values of diameter stenosis, lesion length, maximal balloon pressure, balloon-to-artery ratio, relative vessel stretch, and absolute recoil were not statistically different. Immediate vascular recoil in single implanted Palmaz-Schatz stent is a function of the final expanding balloon diameter, with recoil larger at small-balloon diameters and almost eliminated at large inflation diameters. This finding could contribute to less acute gain, increased restenosis, and higher stent thrombosis rates after stenting vessels of <3-mm diameter. © 1995 Wiley-Liss, Inc.     

Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures—Part VI

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effects on the site of obstruction has been termed “remodeling.” Part VI of this six-part series focuses on atherectomy and restenosis tissue obtained by atherectomy procedures.     

Angioplasty followed by coronary stenting at the anastomotic site of saphenous vein bypass graft with the native vessel: A case that needs special procedural strategy

In this report we describe a case in which a saphenous vein graft stenosis at the site of anastomosis with the left anterior descending artery (LAD) was dilated with a special Controlled Angioplasty Technology (CAT) balloon, and then stented. Balloon angioplasty and stenting at the site of anastomosis represents a technical problem because of diameter discrepancy and needs special attention in order to avoid minor or major complications. Cathet. Cardiovasc. Diagn. 42:61–63, 1997. © 1997 Wiley-Liss, Inc.     

Retrograde dilatation of a totally occluded ostial left anterior descending artery from saphenous venous graft in the descending aorta following stenting of the aorto-ostial graft restenosis in a patient with left main coronary artery stenosis.

Treatment of native coronary and saphenous vein graft aorto-ostial stenoses with balloon angioplasty is associated with lower procedural success rates and more complications compared with percutaneous transluminal coronary angioplasty of nonostial stenoses. A patient with totally occluded ostial left anterior descending artery at ostium following aortocoronary bypass developed ostial stenosis at the saphenous vein graft in the descending aorta. The aorto-ostial lesion of saphenous vein graft was successfully stented and was followed by retrograde dilatation of the left anterior descending artery, and the totally occluded ostial lesion was reopened. The ischemia was eliminated following the procedure.     

Reduced distal embolization with transluminal extraction atherectomy compared to balloon angioplasty for saphenous vein graft disease

Extraction atherectomy utilizes suction aspiration as an attempt to limit distal emboll during atherectomy. We sought to test the hypothesis that extraction atherectomy produces less distal embolization than balloon angioplasty when treating saphenous vein grafts. Among 163 consecutive, nonrandomized patients, 103 patients underwent transluminal extraction catheter (TEC)^® atherectomy with or without adjunctive balloon angioplasty, and 60 patients had conventional balloon angioplasty. Both groups showed comparably high procedural success rates (TEC 90.3%, angioplasty 83.3%, P = NS). TEC cases had a significantly lower incidence of angiographic distal embolization, compared with angioplasty (3.9% vs. 16.7%, P = 0.005). In cases with angiographic evidence of thrombus in the grafts, TEC maintained a significantly lower incidence of distal embolization than angioplasty (5.6% vs. 31.8%, P = 0.004). There were no statistical differences between the two groups regarding the incidence of other procedure-related complications, including death, myocardial infarction, or emergency coronary artery bypass grafting. TEC atherectomy appears to have a significantly lower incidence of distal embolization than balloon angioplasty when treating saphenous vein grafts, particularly in the presence of angiographically apparent thrombus. © 1996 Wiley-Liss, Inc.     

Excimer laser angioplasty vs. balloon angioplasty in saphenous vein bypass grafts: Quantitative angiographic comparison of matched lesions

Technologies which ablate or debulk tissue may result in better angiographic outcomes by altering the elastic properties of the vessel wall. Accordingly, the procedural outcomes of 88 vein graft lesions treated by either excimer laser angioplasty with adjunct balloon angioplasty (PELCA + PTCA, n = 44) (Spectranetics CVX-300, 1.4-, 1.7-, or 2.0-mm catheters) or balloon angioplasty alone (PTCA, n = 44) were analyzed by quantitative angiography (Cardiac Measurement System). Lesions were individually matched for vessel position, reference diameter (RD), and minimal luminal diameter (MLD). Matching was deemed adequate as the preprocedure MLD (PELCA + PTCA, 1.14 ± 0.48 mm; PTCA, 1.20 ± 0.47 mm) and RD (PELCA + PTCA, 3.23 ± 0.56 mm; PTCA, 3.25 ± 0.57 mm) were not significantly different. There were also no significant differences between PELCA + PTCA- and PTCA-treated lesions with respect to patient age, graft age, lesion length, symmetry, and plaque area. Balloon diameter at maximal inflation was 2.77 ± 0.55 mm (PELCA + PTCA group) and 2.84 ± 0.59 mm (PTCA group), P = NS. Final MLD postprocedure was 2.17 ± 0.54 mm and 2.19 ± 0.55 mm for PELCA + PTCA- and PTCA-treated lesions (P = NS), respectively. Vessel stretch [(balloon diameter − MLD pre)/RD], elastic recoil [(balloon diameter − MLD post)/RD], and acute gain [(MLD post − MLD pre)/RD] were calculated and normalized for vessel size (RD). Vessel stretch (PELCA + PTCA, 0.60 ± 0.22; PTCA, 0.59 ± 0.24; P = NS), elastic recoil (PELCA + PTCA, 0.28 ± 0.18; PTCA, 0.26 ± 0.16), and acute gain (PELCA + PTCA, 0.34 ± 0.24; PTCA, 0.31 ± 0.23; P = NS) were not significantly different between the two treatment groups. In a matched population of successfully treated vein graft lesions, PELCA + PTCA did not reduce elastic recoil or improve immediate angiographic outcome, as compared with PTCA alone. © 1996 Wiley-Liss, Inc.     

Comparison of conventional and cutting balloon angioplasty for congenital and postoperative pulmonary vein stenosis in infants and young children

Background: Pulmonary vein stenosis (PVS) is a rare and often lethal condition in children. The optimal treatment for congenital and postoperative PVS is unknown. Methods and Results: We compared outcomes of conventional balloon angioplasty performed for PVS from 1999 to 2003 against cutting balloon angioplasty performed from 2004 to 2007. A total of 100 previously undilated pulmonary veins in 54 patients were studied: 48 veins dilated with conventional balloons and 52 with cutting balloons. Acute results included significantly reduced gradients and increased lumen diameters with both treatments. Acutely, cutting balloon angioplasty and conventional angioplasty yielded similar relative reduction of the PVS gradient (median 78% vs. 63%, P = 0.08) and increase in lumen diameter (median 77% vs. 59%, P = 0.07). There was one procedural death of a critically ill infant, and four cardiac arrests, but no adverse events necessitating surgical intervention. Survival free from reintervention was poor in both groups, and shorter in the cutting balloon group (73% at 1 month, 11% at 6 months, and 4% at 1 year) than in the conventional angioplasty group (77% at 1 month, 35% at 6 months, and 23% at 1 year; P = 0.01). Conclusions: Both conventional and cutting balloon angioplasty were effective at decreasing gradient and increasing lumen size acutely in patients with congenital and postoperative PVS, but reintervention was common with both treatments. Both methods of angioplasty provided limited benefit, and neither was curative for this complex disease. © 2010 Wiley‐Liss, Inc.     

Exercise‐induced saphenous vein graft spasm prevented by stenting

Recurrence of anginal symptoms following coronary artery bypass surgery is usually secondary to graft closure or progression of native vessel disease. The present case demonstrates severe exercise‐induced saphenous vein graft (SVG) spasm associated with transmural ischemia refractory to maximal vasodilator therapy. Symptoms resolved and exercise electrocardiography normalized following stenting of SVG regions demonstrating spasm. © 2017 Wiley Periodicals, Inc.     

Internal mammary artery graft angioplasty: Acute and long-term outcome

Secondary to the low attrition rate of internal mammary artery grafts, limited data are available on the clinical and angiographic outcome of patients who have undergone balloon angioplasty of an internal mammary artery stenosis. This study examined a consecutive series of 68 patients who underwent balloon angioplasty of an internal mammary artery graft over a 9-year period. Procedural success was achieved in 60 of 68 (88%) patients. The primary reason for procedural failure was extreme vessel tortuosity. There were no major in-hospital complications. Angiographic follow-up was obtained in 78% of the patients with an angiographic restenosis rate of 19%. The overall event-free survival in patients with an initially successful procedure was 92%. In conclusion, internal mammary artery balloon angioplasty has both an excellent initial success rate as well as a low incidence of restenosis and repeat target lesion revascularization. Cathet. Cardiovasc. Diagn. 44:153–156, 1998. © 1998 Wiley-Liss, Inc.     

Transluminal extraction atherectomy for aortosaphenous vein graft stent restenosis

The optimal strategy to manage in-stent saphenous vein graft (SVG) restenosis has not been studied. We present two cases in which transluminal extraction atherectomy (TEC) was used successfully for the treatment of SVG stent restenosis. TEC atherectomy may provide an alternative to conventional balloon angioplasty for such patients. © 1996 Wiley-Liss, Inc.     

Retrograde embolization during saphenous vein graft angioplasty

Angioplasty of degenerated saphenous vein grafts is not infrequently complicated by distal embolization of atheromatous debris. We describe an uncommon case in which balloon angioplasty of an old vein graft to a second diagonal branch of the left anterior descending coronary artery was followed by distal embolization. However, the embolization occurred in a retrograde fashion distal to the anastomotic site, resulting in occlusion of the upstream first diagonal branch. The reasons for its occurrence are discussed, together with suggestions for its recognition. Cathet. Cardiovasc. Intervent. 46:205–209, 1999. © 1999 Wiley-Liss, Inc.     

Retrieval of occluding unexpanded palmaz-schatz stent from a saphenous aorto-coronary vein graft

The Palmaz-Schatz coronary stent is used frequently to reduce the rate of restenosis of balloon angioplasty in saphenous vein grafts. In many European centers, the stent, manually crimped on a balloon, is advanced across the stenosis without a protective sheath. This report describes a patient in whom an attempt to deploy a stent in the orifice of a saphenous vein graft was complicated by dislodgement of the unexpanded stent from the balloon. The unexpanded stent caused immediate occlusion of the vein graft and severe ischemic symptoms. The stent was retrieved by inflation of another balloon in the graft, distal to the stent, pulling the balloon toward the guiding catheter, and then withdrawing the whole system.     

Endoluminal stenting of narrowed saphenous vein grafts: long-term clinical and angiographic follow-up

From April 1986 through April 1993, 58 intracoronary stents (41 Wall and 17 Wiktor stents) were implanted for the treatment of saphenous vein graft stenosis in 40 symptomatic patients. The indication was a primary stenosis in 44 and restenosis in 14 procedures. In-hospital complications were subacute stent thrombosis (2%), myocardial infarction (2%), and emergency coronary artery bypass grafting (CABG) (2%). Complications during a mean follow-up period of 42±27 months were restenosis (35% by patient, 33% by lesion), myocardial infarction (12%), late bypass grafting (12%), and death (7%). On quantitative coronary angiographic analysis, the mean minimal luminal diameter (and its confidence interval) increased from 1.3 mm (1.1–1.5 mm, preprocedure) to 2.9 mm (2.7–3.1 mm, postprocedure) and 2.2 mm (2.0–2.5 mm, 6 months follow-up, 95% angiographic follow-up). Progression of the underlying coronary artery disease and restenosis were the main reasons for a continual decline of the proportion without cardiac event on a Kaplan-Meier estimate. Restenosis occurred in one-third of cases beyond the first 6 months of follow-up. A relative risk ratio analysis for restenosis, performed on 14 variables, disclosed an increased risk for the following variables: (1) stenting of the proximal, distal or anastomosis part of the vein graft (relative risk 2.41, confidence interval: 1.28–3.59), (2) the implantation of stents <4.5 mm (2.59, 1.18–4.00), and (3) stenting of a redo–CABG vein graft (2.37, 1.17–3.58). Saphenous vein graft stenting seems to be characterized by excellent immediate clinical and angiographic results; in particular, stent thrombosis is rare. In this study, it appears that restenosis rates are lower than after conventional balloon angioplasty, but several procedural factors are related to an increased restenosis risk. Despite a lasting success in the majority of stented lesions, the estimated proportion without cardiac event is low at 5 years follow-up. Progression of the underlying coronary artery disease, a non-procedure-related event, constitutes the major limitation of saphenous vein graft stenting. © 1994 Wiley-Liss,Inc..     

Is provisional stenting the effective option? The WIDEST study (Wiktor stent in de novo stenosis)

AIM—To compare the immediate and late outcomes of patients treated by a policy of routine stent implantation with routine balloon angioplasty and the use of stents only when an ideal result has not been obtained.
METHODS—A nine centre, multinational, randomised study of 300 patients with coronary artery disease thought suitable for treatment of a single lesion by balloon angioplasty or stent implantation. Only new lesions in patients who had not undergone previous bypass surgery were included, and totally occluded vessels were excluded.
RESULTS—The initial procedure was considered successful in 96% of patients. There was more complete angiographic restoration of luminal diameter in patients treated by elective stent (minimum lumen diameter (MLD) 2.68 mm for stent v 2.27 mm for balloon; p < 0.007), but analysis of the subgroup of balloon angioplasty patients who crossed over to stenting showed that they achieved similar results to the elective stent group. Late luminal loss was greater in stented patients than in those undergoing balloon angioplasty only, and by six months the angiographic benefit of stenting had disappeared (MLD 1.90 mm for stent group v 2.00 mm for balloon angioplasty). Angiographic and clinical results in the balloon angioplasty group were assisted by the high crossover rate (30.1%). Both groups had similar symptom relief, with 58.9% of patients improving by two or more angina grades. The need for further revascularisation was also similar in the two groups at one year (18.2% in the stented group v 17.1% in the balloon angioplasty group). Haemorrhagic complications at the local arterial entry site were more common than expected and were distributed equally between the patients receiving full anticoagulation and those receiving antiplatelet treatment only. The results of both Wiktor stent placement and balloon angioplasty were similar to the findings in the stent group in previous randomised studies (Benestent II, STRESS).
CONCLUSIONS—Provisional stenting appears to offer the same longer term outcome as elective stenting in this selected group of patients. Improvement in the results of conventional balloon angioplasty in the past 10 years means that a policy of obtaining an ideal result without the use of stents appears to be practicable in many of these patients, with consequent cost savings.


Keywords: stent; balloon angioplasty; coronary angioplasty     

Implantation of half palmaz-schatz stents in short aorto-ostial lesions of saphenous vein grafts

Two cases are presented in which a half Palmaz-Schatz stent was implanted in a short lesion located in the ostium of a saphenous vein graft. Aorto-ostial stenoses are a technical challenge for balloon angioplasty and stenting. Short stents may offer several advantages as regards deployment, positioning, thrombogenicity, and restenosis. © 1993 Wiley-Liss, Inc.