1433例慢性完全闭塞病变的冠状动脉支架术治疗

目的探讨提高CTO病变PCI成功率的方法.方法对1993年6月至2004年6月实施PCI治疗的1433例CTO患者的临床资料、病变特征和PCI治疗结果进行回顾性分析.PCI人选标准有心肌缺血的主观表现或客观证据.结果男性1176例(占82.1%),女性257例(占17.9%),年龄25～86(平均59.8±11.3)岁.共涉及CTO靶血管1823支,靶病变共1855处.CTO平均闭塞时间48.3±32.6(1～204)个月.绝对性CTO(TIMI血流0级)1646支(占90.3%).有桥侧支形成的靶CTO血管339支(占17.6%).逆向侧支循环者1035支(占56.8%).刀切状CTO607支(占33.2%).CTO闭塞段≥15mm的CTO病变1042支(占57.2%).病变近端或病变处弯曲≥90度有279支(占15.3%).病变近端或病变处钙化246支(占13.5%).距闭塞处＜1mm距离有分支发出的CTO病变血管499支(占27.3%).CTO位于血管开口处为849支(占46.6%),位于血管远端434支(占23.8%).CTO靶血管共置入冠状动脉支架1853枚.支架长度平均(24.8±6.7)mm.支架直径平均(2.9±0.7)mm.72例CTO患者置入药物洗脱支架95枚,其中Cypher支架44枚、Taxus支架51枚.术中99例行临时起搏术(占6.9%);33例行IABP治疗(占2.3%).经股动脉完成1291例(占90.1%),经桡动脉完成142例(占9.9%).168例应用了双侧冠脉造影、3例应用了对侧导丝、67例应用了平行导丝(parallel)或导丝互参照(seesaw)、21例应用了双导丝(buddy)技术.行旋磨术3例.共开通1328例患者CTO靶病变1694处,全部植入支架,术终1322例患者的1688处靶病变达TIMI3级血流(89.5%),病例成功率为92.3%(1322/1433),病变成功率为91.0%(1688/1855).功能性CTO、无桥侧支CTO、鼠尾状CTO、闭塞段15mmCTO的病变成功率较高,P＜0.05.失败的105例中82例因导丝不能通过CTO病变(占失败病例的78%),23例因球囊不能跨越病变(占22%),术中无死亡病例,支架内急性血栓形成2例,心包穿孔9例(发生率0.6%).术后住院期间共死亡3例,总住院病死率为0.2%,均为PCI失败者,其中2例猝死,1例死于慢性肾衰急性发作并脑梗塞.术后支架内亚急性血栓形成4例(发生率0.3%),均经急诊PCI治愈.结论本组CTO病变及病例成功率略高于国内大多数报导,且术中无死亡等严重并发症发生.在高难度CTO的开通成功率上与国外大中心相似,可能得益于我们较多采用亲水涂层或表面超滑的硬导丝,适当地应用平行导丝、导丝互参照和双导丝技术.另外,仔细阅读造影图像,科学、合理地安排有经验的术者和手术时间,以及手术组密切协作也对提高CTO治疗成功率有一定影响.     

慢性完全闭塞病变2 051例的临床及影像学分析

目的总结慢性完全闭塞(CTO)冠状动脉(冠脉)病变的临床和影像学特点。方法回顾性分析1989年6月至2005年5月诊断冠心病并经冠脉造影证实有CTO病变患者的临床和冠脉造影资料。结果有一支以上CTO病变者共2051例,涉及2848支CTO血管;年龄25~86(60.5±10.5)岁;男1051例(占80.5%)。其中临床不稳定型心绞痛1027例(占50.1%),有心肌梗死史878例(占42.8%);吸烟者900例(占43.9%),合并高血压病1142例(占55.7%),糖尿病451例(占22.0%),高脂血症394例(占19.2%)。病变血管包括有桥状侧支循环形成的CTO血管985支(占34.6%),CTO闭塞段呈刀切状为909支(占31.9%);≥15mm的CTO病变1632支(占57.3%);病变近端或病变处弯曲≥45度有1124支(占39.5%),病变近端或病变处钙化501支(占17.6%);闭塞处有分支发出的CTO血管834支(占29.3%);CTO位于血管开口处为1149支(占47.1%),位于血管远端1341支(占24.1%)。结论本组CTO病例有吸烟、高血压、糖尿病及高脂血症等冠心病危险因素的比例较高;患有不稳定型心绞痛、陈旧性心肌梗死、心力衰竭、心律失常、脑血管病的比例亦较高;病变血管具有桥侧支、刀切状CTO断端、闭塞长度≥15mm、病变近端或病变处弯曲≥45度,较多患者影像上存在中重度钙化、闭塞处有分支发出及CTO位于血管开口处等特征。这些临床及影像学特征可能增加CTO病变行PCI治疗的难度,对成功率有一定影响。糖尿病、高血压病、吸烟、心功能、病程对CTO病变影像学特征有一定影响。     

冠状动脉慢性完全闭塞合并钙化病变的介入治疗

目的 总结冠状动脉慢性完全闭塞(CTO)合并钙化病变经皮冠状动脉介入治疗(PCI)的经验和住院期临床疗效.方法 研究对象为1995年6月至2007年2月CTO合并钙化病变接受PCI的患者726例,其中仅经冠状动脉造影检出624例,经血管内超声(IVUS)检出102例.分析比较两种方法 检出CTO合并钙化病变患者的临床、病变特征和PCI结果 .结果 共处理冠状动脉造影检出624例的728支靶血管和732处靶病变.病例成功率80.6%(503/624),病变成功率80.2%(587/732),失败的121例中87例因导丝通过失败,21例球囊失败,8例发生并发症,5例术后TIMI血流2级,住院期主要不良心脏事件(包括死亡、急性心肌梗死、再次血管重建)发生率1.1%(7/624).共处理IVUS检出102例的120支靶血管和127处靶病变,病例和病变成功率分别为89.2%(91/102)和88.2%(112/127),均高于经冠状动脉造影检出的患者(P<0.05),失败的11例中7例因导丝通过失败,2例球囊通过失败,发生并发症和术后TIMI血流2级各1例,住院期主要不良心脏事件发生率1.0%(1/102).结论 CTO合并钙化病变的PCI可通过正确采用介入治疗器械和技术而获得较高的成功率和较理想的近期疗效,IVUS检测有助于提高PCI开通率.     

慢性完全闭塞冠状动脉病变1148例患者的介入治疗

目的　总结慢性完全闭塞(CTO)冠状动脉病变经皮冠状动脉介入(PCI)治疗的技术及疗效。方法　对1993年6月至2004年12月实施PCI治疗的1148例CTO患者的临床资料、病变特征和PCI结果进行回顾性分析。共涉及CTO靶血管1458支,靶病变1494处,CTO平均闭塞时间(49. 1±31. 6)个月,置入冠状动脉支架1499枚。结果　病例成功率为90 .2% ( 1036 /1148 ),病变成功率为88 。2% (1317 /1494)。随CTO闭塞时间延长,PCI成功率降低,闭塞部位呈刀切状、存在桥侧支、闭塞长度≥15mm的CTO病变PCI成功率降低(P<0. 05)。操作失败112例,其中82 .1%因导丝不能通过CTO病变, 17 .9%因球囊不能跨越病变。术中无死亡病例,支架内急性血栓形成2例(0. 2% ),术中及术后共发现心包穿孔9例( 0 .8% )全部处理成功。术后住院期间共死亡3例(0 .3% ),支架内亚急性血栓形成3例(0 .3% ),总的主要不良心脏事件发生率为0 .6% (7 /1148)。存活患者出院心绞痛症状缓解率为87. 1%。结论　在技术成熟的心脏中心,PCI治疗CTO病变可获得较高的成功率和较好的临床效果。     

介入治疗开通慢性完全闭塞病变的长期临床疗效

目的 评价经皮冠状动脉介入治疗(PCI)成功开通冠状动脉慢性完全闭塞(CTO)病变对长期临床疗效的影响.方法 对1993年6月至2006年12月连续1332例冠状动脉CTO住院患者的临床资料进行分析.根据PCI结果将患者分为成功组(n=1202)和失败组(n=130),对比两组患者长期生存率、无主要不良心血管事件生存率及接受冠状动脉旁路移植术(CABG)的差别.结果 总病例成功率为90.2%(1202/1332),成功组患者PCI后10年生存率、无主要不良心血管事件生存率均明显高于失败组(分别为76.9%比64.6%,log rank P=0.012;41.8%比27.6%,log rank P<0.001),接受CABG患者则显著少于失败组(4.3%比14.6%,P<0.001).结论 PCI开通CTO病变可明显提高患者长期生存率和无主要不良心脏事件生存率,并减少对CABG的需求.     

介入治疗开通慢性完全闭塞病变的长期临床疗效

目的 评价经皮冠状动脉介入治疗(PCI)成功开通冠状动脉慢性完全闭塞(CTO)病变对长期临床疗效的影响.方法 对1993年6月至2006年12月连续1332例冠状动脉CTO住院患者的临床资料进行分析.根据PCI结果将患者分为成功组(n=1202)和失败组(n=130),对比两组患者长期生存率、无主要不良心血管事件生存率及接受冠状动脉旁路移植术(CABG)的差别.结果 总病例成功率为90.2%(1202/1332),成功组患者PCI后10年生存率、无主要不良心血管事件生存率均明显高于失败组(分别为76.9%比64.6%,log rank P=0.012;41.8%比27.6%,log rank P<0.001),接受CABG患者则显著少于失败组(4.3%比14.6%,P<0.001).结论 PCI开通CTO病变可明显提高患者长期生存率和无主要不良心脏事件生存率,并减少对CABG的需求.     

冠状动脉旁路移植术后桥血管造影特点分析

目的总结冠状动脉旁路移植术(CABG)后桥血管造影特点,分析相关因素对桥血管通畅率的影响。方法选择2004年4月至2006年4月我院CABG术后因心绞痛复发再入院行冠状动脉造影(CAG)的256例患者,男性218例,平均年龄(61.2±9.7)岁。CABG到复查CAG的间隔时间(50.9±40.1)个月。共722支桥血管,其中左乳内动脉(LIMA)桥215支,大隐静脉(SV)桥485支,左桡动脉(RA)桥19支,右乳内动脉(RIMA)桥3支。桥血管造影完全闭塞或狭窄≥75%视为桥血管病变。结果31.6%(228/722)的桥血管发生病变。LIMA桥病变率13.5%(29/215),SV桥病变率39.2%(190/485),RA桥病变率42.1%(8/19),RIMA桥病变率33.3(%1/3)。术后1年内LIMA桥和SV桥病变率分别达14.6%和32.9%,之后随时间缓慢增加。不同靶血管的SV桥通畅率有明显差别。手术年龄<50岁者桥血管病变率增加。性别、序贯吻合及综合危险因素对桥血管通畅率无明显影响。结论CABG术后桥血管病变较常见,是造成术后心绞痛复发的重要原因。LIMA桥的通畅率明显优于SV桥。不同桥血管、不同靶血管、手术年龄均明显影响桥血管通畅率。     

冠状动脉搭桥术后症状复发患者的血管造影特征和缺血原因分析

目的:分析总结冠状动脉搭桥术(CABG)术后症状复发患者的冠状动脉造影(CAG)特点,探讨心肌缺血原因及其治疗对策。方法:对74例CABG术后心肌缺血复发患者行冠状动脉造影及桥血管造影,总结其自体冠状动脉和移植血管病变特点,分阶段归纳心肌缺血的可能原因。结果:74例患者中男性72例,女性2例,平均年龄(63.3±9.3)岁,平均复查时间(37.79±37.65)个月。共174支移植血管,其中左乳内动脉桥44支,大隐静脉桥126支,桡动脉桥4支。左乳内动脉桥完全闭塞20.5%(9/44),狭窄18.2%(8/44);静脉桥闭塞40.5%(51/126),狭窄7.1%(9/126);4例桡动脉搭桥,2例有狭窄;竞争血流现象的发生率为12.2%(9/74);32.5%(24/74)的患者自体冠状动脉病变加重;13.5%(10/74)的患者存在再血管化不完全;CABG术后早期(1个月以内)心肌缺血的主要原因是左乳内动脉桥吻合口狭窄(占50%),1年以内主要与静脉桥血管狭窄和闭塞有关(占44.7%),而1年和5年以后则绝大多数缘于静脉桥的闭塞(占46.7%)。45.8%(34/74)的患者行药物保守治疗,9.5%(7/74)的患者行再次外科搭桥(reCABG),29.7%(22/74)接受了自体血管的介入治疗(PCI),12.2%(9/74) 行桥血管的介入治疗。移植血管的介入治疗成功率接近90%,自体血管的介入治疗成功率72.2%。结论:CABG后部分患者心肌缺血可以复发,其中移植血管病变是引起心肌缺血的主要原因,其它原因有再血管化不完全、自体血管病变加重等,自体血管和狭窄桥血管的介入治疗对CABG后心肌缺血复发患者具有较高的成功率和较低的并发症发生率,因此仍然是可取的治疗方法。     

多层螺旋CT指导下慢性闭塞病变的介入治疗

目的探讨多层螺旋CT(MDCT)对于慢性闭塞(CTO)病变PCI结果有无指导作用。方法选择在我院行冠状动脉MDCT证实为冠状动脉CTO,并在我院心内科行择期PCI的冠心病患者35例。根据CT图像判断CTO病变的位置、性质及钙化程度,闭塞血管远段血流分级以及闭塞近段管腔直径等指标是否对PCI结果及操作时间有预测及指导意义。结果 35例患者中有37支闭塞血管,其中21支(56.8%)获得再通,未再通血管中43.8%位于右冠状动脉,56.2%位于血管近段,钙化斑块占56.2%,80.0%的血管在CT图像上无法看到闭塞远段造影剂渗漏。TIMI血流(P=0.0128)及闭塞部位血管病变的性质(P=0.0703)是CTO病变再通的影响因素。闭塞血管所处节段(P=0.0157)以及闭塞血管所处位置(P=0.0704)是开通CTO病变操作时间的影响因素。结论MDCT可以准确判断CTO病变的走行,评价其斑块的性质及分布。闭塞病变远段有无血流及斑块的性质是PCI是否成功的预测因素。闭塞血管的不同以及所处节段的不同是PCI操作时间长短的预测因素。     

冠状动脉慢性完全闭塞病变的临床特点分析

目的讨论冠状动脉慢性完全闭塞的治疗措施及效果。方法入选2010年1月至2013年3月江西省人民医院干部心血管一科住院的冠心病患者138例,冠状动脉造影显示为冠状动脉慢性完全闭塞(CTO)病变。回顾性分析138例CTO患者血运重建治疗措施以及效果。结果 138例CTO患者,共162支慢性完全闭塞血管,主要累及前降支(LAD)52支,回旋支(LCX)27支,左主干(LM)9支及右冠状动脉(RCA)60支。145支慢性完全闭塞血管行经皮冠状动脉腔内成行(PTCA)治疗,130支血管成功支架置入101个。17例患者行冠状动脉旁路移植术(CABG)。结论 CTO临床表现多样,但缺乏特异性,可以选用PTCA及支架术或CABG治疗。     

Feasibility of percutaneous coronary interventions in early postcoronary artery bypass graft occlusion or stenosis

BACKGROUND: With continuing technical advances in percutaneous coronary interventions (PCI) for coronary artery disease (CAD), patients undergoing coronary artery bypass surgery (CABG) often have complex coronary anatomy that is not ideal for PCI. Because of the complex anatomy, these patients have a higher risk of early graft occlusion. The feasibility of PCI in the treatment of early graft occlusion is not well established. METHODS: A retrospective chart review was performed of patients presenting with recurrent ischemia within three months post-CABG and at one-year follow-up. RESULTS: Forty-six patients with 156 grafts were identified. Three presented with STEMI, 21 with NSTEMI, 21 with unstable angina, and one with congestive heart failure. Sixty-three grafts were occluded or stenosed (>70%). Twenty-seven grafts (43%) in 17 patients were not amenable to PCI. The other 34 grafts (54%) in 23 patients underwent successful PCI. PCI was performed upon native vessels and occluded grafts with equal frequency. Six patients had patent grafts. At one-year follow-up, six of 23 patients in the PCI group were readmitted with ischemia; five vessels (14%) in four patients had restenosed. There were no deaths. In the group with no PCI, 11 of 23 patients were readmitted with ischemia with one death. CONCLUSION: PCI for early post-CABG occlusion was safely performed in slightly more than half of target vessels. PCI was performed upon native vessels and occluded grafts with equal frequency. After initial PCI success, the clinical target vessel restenosis rate was 14% at one-year follow-up.     

Progression from stenosis to occlusion in the proximal native coronary artery after coronary artery bypass grafting

Coronary artery bypass grafting (CABG) is an established treatment for multivessel coronary artery disease. However, problematic situations are occasionally encountered after CABG, such as disease progression in the native coronary artery with graft occlusion, which causes difficulty in revascularization. The purpose of this study was to evaluate changes in the native coronary artery after CABG. Between 2009 and 2012 in our institution, 351 patients underwent CABG, and 768 bypass grafts were anastomosed to non-occluded coronary arteries. Of these, 489 bypass grafts had available early postoperative angiographic results (≤6 months) suitable for assessment in this study. We defined malignant graft failure after CABG to be bypass graft occlusion and de novo complete occlusion of the target native coronary artery proximal to the graft anastomosis site. In the early angiographic results, 17 grafts were occluded (17/489; 3.5 %). Two of the grafts displayed malignant graft failure (a saphenous vein graft to the right coronary artery and a saphenous vein graft to the diagonal branch) (2 of 17 occluded grafts, and 2 of 489 studied grafts). Of the patent bypass grafts, 24 involved progression to occlusion in the proximal native coronary artery (19 saphenous vein grafts, 4 left internal thoracic artery grafts, and 1 right internal thoracic artery graft). Malignant graft failure was uncommon during short-term follow-up after CABG. At the same time, disease progression in the proximal native coronary artery from stenosis to occlusion following patent bypass grafting was relatively common, especially for vein grafts.     

Comparison of percutaneous coronary intervention in native coronary arteries vs. bypass grafts in patients with prior coronary artery bypass graft surgery

ObjectiveTo compare the procedural and clinical outcomes of prior coronary artery bypass graft surgery (CABG) patients undergoing percutaneous coronary intervention (PCI) in native arteries vs. bypass grafts.MethodsThe medical and catheterization records and the angiograms of 142 consecutive prior CABG patients who underwent 165 PCI of 247 lesions at our institution between January 1, 2003, and December 31, 2006, were retrospectively reviewed.ResultsMean age was 66±10 years and 99% were men: 79 and 63 patients underwent native coronary or bypass graft PCI, respectively. Compared to patients undergoing bypass graft PCI, those undergoing native coronary artery PCI were younger (mean age 64±10 vs. 68±10 years, P=.008), more likely to present with stable angina (29% vs. 8%, P=<.001), and presented earlier after CABG (after a mean of 9±6 vs. 12±5 years, P<.01). Compared to bypass graft PCI, native coronary PCI was more likely to be performed with drug-eluting stents (88% vs. 57%, P<.001) and was associated with lower risk of no-reflow (3% vs. 24%, P<.001). After a mean follow-up of 2.5±1.1 years, both groups of patients had similar but high incidence of myocardial infarction, repeat PCI, and death.ConclusionsPrior CABG patients undergoing native coronary artery PCI have lower procedural risk, but similar postprocedural clinical outcomes compared to patients undergoing bypass graft PCI. If feasible, native coronary arteries may be the preferred PCI target in prior CABG patients.     

Usefulness of dipyridamole stress echocardiography for predicting graft patency after coronary artery bypass grafting

Noninvasive techniques often provide controversial results in patients who have coronary artery bypass grafts (CABGs). Vasodilator stress echocardiography allows semi-simultaneous imaging of CABG flow and segmental left ventricular wall motion. To assess the comparative and additive value of regional flow and function for noninvasive evaluation of graft patency status, we evaluated 110 consecutive patients who underwent CABG and who were scheduled for coronary angiography. All patients underwent stress echocardiography with dipyridamole (0.84 mg/kg) and atropine (1 mg), including wall motion analysis by 2-dimensional echocardiography and Doppler evaluation of flow reserve of each CABG. Echocardiographic findings were compared with angiographic data. Four patients had inadequate acoustic windows. The remaining 106 patients had 226 grafts performed. Stress echocardiography showed 67% sensitivity, 91% specificity, and 71% accuracy for identification of 50% to 100% stenosis in the graft or in the recipient coronary vessel. There was a fair agreement with angiography (kappa coefficient 0.60). Identification of impaired coronary bypass flow reserve (i.e., <1.9 for internal mammary grafts and <1.6 for saphenous vein grafts) by Doppler had 91% sensitivity, 88% specificity, and 89% accuracy for graft stenosis. There was good agreement with angiographic findings (kappa 0.77). The combination of the 2 techniques achieved 93% sensitivity, 93% specificity, and 93% accuracy, showing a very good agreement with the patency status of the grafts as evaluated at angiography (kappa 0.85). The combined assessment of wall motion and flow reserve in patients who underwent CABG is feasible and provides an accurate estimate of graft patency status by increasing sensitivity of stress echocardiography and specificity of Doppler flow reserve.     

65例冠状动脉慢性闭塞病变介入治疗临床分析 (英文)

目的：分析冠状动脉慢性完全闭塞（CTO）病变患者经皮冠状动脉介入治疗（PCI）疗效的影响因素。方法：回顾分析我院2010年1月至2012年12月期间65例患者72处 CTO病变介入治疗的临床资料、病变特征和PCI的疗效。结果：CTO病变 PCI成功率为91.67%（66/72）;CTO病变闭塞时间＞12个月者 PCI成功率显著低于3～12个月者（81.48%比97.78%）,闭塞长度＞15mm的 CTO病变 PCI成功率显著低于闭塞长度≤15mm者（78.26%比97.96%）;断端呈刀切状的 CTO病变 PCI 成功率显著低于鼠尾状者（71.43%比96.55%）,P 均＜0.05;PCI失败有6处,其中4处因导丝未能通过病变,2处因球囊未能通过病变;介入术中并发症发生率为7.69%,住院期间均无主要不良心血管事件;术后心绞痛症状缓解率为90.16%。结论：冠状动脉慢性完全闭塞病变经皮冠状动脉介入治疗成功率与病变特征、CTO病变闭塞时间等因素有关。     

冠状动脉旁路移植术后病变桥血管的介入治疗

目的探讨冠状动脉旁路移植(CABG)术后移植血管病变介入治疗的效果。方法对CABG术后旁路移植血管的病变进行介入治疗。术后即刻进入临床随访,记录心脏事件的发生,患者术后6个月复查造影。结果对66例患者的74支病变桥血管(83处病变)进行了介入治疗,造影成功率为96.97%(64/66),临床成功率95.45%(63/66)。术中出现无复流现象2例,1例经处理恢复血流,1例处理无效。远端栓塞1例,D型夹层造成血管急性闭塞1例,重新置入支架后成功。住院期间无心脏事件发生。64例患者完成6个月的临床随访,心脏事件发生率为31.3%(20/64)。37例患者接受了造影检查,支架内再狭窄发生率为32.5%(13/40)。结论桥血管病变的介入治疗是可行、安全和有效的。     

Lipid lowering and coronary bypass graft surgery

This article reviews the rationale for lipid lowering in patients who have coronary heart disease, and specifically for post-bypass patients. It has been well demonstrated that after coronary artery bypass graft surgery, atherosclerosis continues to progress in the native circulation and develops at an accelerated rate in saphenous vein bypass grafts. During the last decade, numerous clinical trials based on angiographic or clinical outcomes have clearly shown the beneficial effect of lipid lowering in coronary heart disease. Three trials (CLAS, post-CABG, and CARE) have demonstrated delayed progression of atherosclerosis in SVGs and/or a reduction of cardiac deaths, nonfatal MI, and the need for revascularization after lowering LDL-cholesterol. The recommended target of LDL cholesterol level of more than 100 mg/dl can be safely reached with diet and monotherapy using one of the statin drugs (HMG-CoA reductase inhibitors). Despite this widely-circulated information, there appears to be inadequate public and professional awareness of the importance of properly managing hyperlipidemia after coronary artery bypass graft surgery.     

Comparative results of transluminal extraction coronary atherectomy in saphenous vein graft lesions with and without thrombus

Objectives. The purpose of this retrospective study was to compare the results of transluminal extraction coronary atherectomy in saphenous vein graft lesions with and without angiographic thrombus.

Background. Percutaneous interventions in lesions with thrombus are associated with reduced procedural success and increased risk of complications. Use of the transluminal extraction catheter, which cuts and aspirates atheroma and thrombus, has been advocated as a potential revascularization strategy for lesions with thrombus.

Methods. Baseline patient characteristics, lesion morphology, immediate angiographic results, in-hospital complications and follow-up were prospectively entered into an interventional cardiology data base. The results of transluminal extraction coronary atherectomy in saphenous vein bypass grafts with angiographic thrombus were compared with results in similar grafts without angiographic thrombus.

Results. Transluminal extraction coronary atherectomy was performed in 175 patients with 183 vein graft lesions, including 59 lesions (32%) with thrombus (Group 1) and 124 (68%) without thrombus (Group 2). Compared with lesions in Group 2, lesions in Group 1 were associated with a higher incidence of baseline total occlusion, diffuse disease and abnormal Thrombolysis in Myocardial Infarction (TIMI) grade flow (p < 0.05); more severe diameter stenosis at baseline, after atherectomy and after final angiography (p < 0.05); a lower rate of clinical success (69% vs, 88%, p < 0.01); and more angiographic and clinical complications, including no reflow (p < 0.05), vascular repair (p < 0.05) and Q wave myocardial infarction (p = 0.09).

Conclusions. In transluminal extraction coronary atherectomy of saphenous vein bypass grafts, the presence of thrombus is associated with more baseline lesion complexity, reduced clinical success and increased risk of no reflow, Q wave myocardial infarction and vascular repair.     

Efficacy and safety of anticoagulant therapy started pre-operatively in preventing coronary vein graft occlusion.

Oral anticoagulant therapy with warfarin commenced pre-operatively (n = 102) to prevent coronary artery vein graft occlusions was compared in terms of efficacy and safety with dipyridamole and aspirin (n = 130) in a randomized consecutive series of patients. Anticoagulant therapy was started at least 2 weeks before coronary artery bypass surgery (CABG) and antiplatelet therapy was started at least 3 days before CABG with dipyridamole followed by a combination of 250 mg aspirin once a day via a nasogastric tube 6 h after CABG. Overall, vein graft patency at 3 months after surgery did not differ significantly between the anticoagulant group (203/275, 74%) and dipyridamole-aspirin group (238/311, 77%), but the occlusion rate for grafts with endarterectomy was higher in the anticoagulant (46%) than in the dipyridamole and aspirin group (16%), (P less than 0.05). The rate of peri-operative complications including deaths, re-operation and myocardial infarction was higher in the anticoagulant than antiplatelet group (26.5% vs 13.8%, P less than 0.05). The occurrence of postoperative bleeding complications did not differ significantly between the groups. Thus, oral anticoagulant therapy commenced pre-operatively has no advantages over conventional antiplatelet therapy in patients who undergo CABG. Neither antithrombotic regimens proved to be satisfactory for preventing acute bypass vein graft occlusions in this patient population with advanced coronary artery disease.     

Long term outcomes of saphaneous vein graft intervention in elderly patients with prior coronary artery bypass graft

Objectives To investigate the procedure characteristics and long term follow-up ofpercutaneous coronary intervention （PCI） for sa phaneous vein graft （SVG） lesions in the elderly patients. Methods From December 2005 to December 201 l, 84 graft lesions were treated percumneously. Seventeen were located at proximal anastomosis, 48 were located at SVG body, 19 were located at distal anastomosis. Pri mary endpoint was defined as major adverse cardiovascular events （MACE, composite of cardiac death, target vessel revascularization, acute myocardial infarction）. Results The graft age was 6.7 i 4.0 years. Most anastomosis lesions （80.0%） presented within one year post coro-nary artery bypass grafting （CABG）. Proximal anastomosis lesion had the lowest successful rate for PCI compared with graft body and distal anastomosis lesions （70.6% vs. 91.7%, 79.0%, P 〈 0.05）. The distal embolic protection device was used in 19.1% of patients, most frequently used in body graft PCI （29.2%, P 〈 0.01）. The diameter of the stent was smallest in distal anastomosis group （2.9 ±0.4 mm, P 〈 0.05）. The highest post dilatation pressure was required in the proximal anastomosis （17.8 ± 2.7 atm, P 〈 0.05）. The patients were followed up for 24.3 ±16.9 months. MACE occurred in 18.57% of patients. Incidence of MACE was highest among proximal anastomosis PCI （47.1% vs. body graft PCI 16.7%, distal anastomosis PCI 21.1%; P 〈 0.05）. Old myocardial infarction was the predictive factor for the poor clinical outcomes （P〈 0.04）. Conclusions PCI of SVG lesions is feasible with lower success rate. PCI of ostial graft anastomosis lesions had the lowest procedure success rate and highest MACE rate compared with graft body and distal anastomosis lesions. Old myocardial infarction was a predictive factor of poor outcomes.