Role of glycoprotein IIb/IIIa inhibitors in the treatment of degenerated aortocoronary saphenous vein grafts

Treatment of degenerated vein grafts is a large, growing portion of interventional procedures. Because the operative risk of repeat bypass surgery is substantially increased, percutaneous transluminal coronary angioplasty has been accepted as a less invasive treatment in symptomatic patients with significant stenoses of vein grafts. Stent placement has been established in the randomized SAVED trial as a safe and efficient treatment strategy of degenerated saphenous vein grafts, enhancing acute success, reducing the incidence of subsequent angiographic restenosis, and improving event-free survival. Despite coronary stents and new technological innovations like directional and transluminal extraction atherectomy distal embolization is still a frequent occurrence, with a reported incidence of 10-15% associated with an increased in-hospital mortality. Blockade of the platelet surface glycoprotein IIb/IIIa receptors has been convincingly demonstrated to reduce the ischemic complications of angioplasty in native coronary arteries. In degenerated vein grafts the efficacy of glycoprotein IIb/IIIa inhibitors in reducing distal embolization is uncertain. Major clinical events could not be reduced by glycoprotein IIb/IIIa antagonists administered periprocedurally. But prospective randomized trials are lacking. Protection devices could reduce the incidence of distal embolization during interventions in degenerated saphenous vein grafts. The relative role of these devices compared to pharmacologic interventions will require careful assessment in future clinical trials.